Mid Abdomen Research Articles

1800 Spontaneous Pyomyoma in A Premenopausal Nulliparous Woman without Risk Factors: A Case Report

Study Objective Pyomyoma is a rare complication of leiomyomata that can result in significant morbidity when not diagnosed and treated in timely manner. While most cases occur peripartum, post-uterine instrumentation or following embolization, we report a case of spontaneous pyomyoma with no inciting event necessitating urgent surgical management. Design Case report Setting Academic tertiary care center in Chicago, IL Patients or Participants NA Interventions NA Measurements and Main Results A 49-year-old healthy G0 with known symptomatic myomas presented to the ED with worsening abdominal pain and a blistering, erythematous rash of the right mid abdomen. Her CT demonstrated an enlarged fibroid uterus with an exophytic myoma measuring 28 × 20 × 16cm with focal areas of uterine wall rupture and surrounding fluid and extension into the abdominal wall. Intravenous antibiotics were begun, and she was taken to the operating room. Intraoperatively, she was found to have an enlarged myomatous uterus with a necrotic pedunculated myoma densely adherent to the anterior abdominal wall, gallbladder, liver, omentum, and porta hepatis. The necrotic portion fractured during uterine mobilization and drained more than one liter of purulent fluid. Frozen section was negative for malignancy. An additional suprafascial abscess in the right upper quadrant was drained for an additional 1L of purulent fluid and confirmed infection into the subcutaneous tissue. She underwent a total abdominal hysterectomy, bilateral salpingo-oophorectomy and debulking with residual fibroid capsule seen at the level of the porta hepatis. The patient was discharged home on POD#9; final pathology showed benign degenerated leiomyoma with focal areas of necrosis and inflammation weighing 3538g. Conclusion This is the second case in the literature when a pyomyoma was described in an immunocompetent, premenopausal woman without recent uterine instrumentation. This case highlights how benign myomas may lead to significant morbidity. Although rare, in patients presenting with fever, worsening pain and fibroids, pyomyoma should be considered in the differential.

2170 Endoscopic Management of Gastric Outlet Obstruction Due to a Large Gallstone ("Bouveret's Syndrome")

INTRODUCTION: Bouveret's syndrome is referred to a gastric outlet obstruction due to an impacted gallstone in the duodenum following cholecystoduodenal fistula. Surgery is required in certain cases, but the mortality rate is up to 30 %. Endoscopic management has been reported with a low success rate. We demonstrate a successful endoscopic mechanical and electrohydraulic lithotripsy of a large gallstone causing gastric outlet obstruction. CASE DESCRIPTION/METHODS: A 88 years old female presented with a three-day history of right upper quadrant abdominal pain (RUQ), nausea, and non-bilious vomiting. Past medical history is significant for hypertension, coronary artery disease, and type 2 diabetes. Vital signs were normal. Pertinent findings included tenderness to palpation in the epigastric and RUQ regions, normal bowel sounds, and a loud succession splash. Labs revealed Hgb 10.2 g/dl, WBC 7k/mm3, platelets 289k/mm3, BUN 13 mg/dl, creatinine 0.6 mg/dl. Plain abdominal X-ray showed round calcified structure in the right mid abdomen (Figure 1). CT scan of the abdomen showed 4 cm × 3.5 cm gallstone causing complete obstruction of the duodenum, cholecystoduodenal fistula, pneumoperitoneum, and distended stomach (Figure 2). Upper endoscopy revealed a large gallstone impacted in the first part of the duodenum, extensive ulceration of the duodenal wall with a small perforation at the site of stone impaction (Figure 3). Mechanical and electrohydraulic lithotripsy was performed, and the stone was fragmented into small pieces in the duodenum. There was spontaneously sealed duodenal perforation with fat and omental plug. The endoscopic lithotripsy was performed without difficulty. The patient was improved, tolerated an oral diet, and discharged home in a stable condition. DISCUSSION: Bouveret’s syndrome is a rare cause of gastric outlet obstruction and characterized by impaction of a gallstone within the pylorus or duodenum. It occurs mostly in elderly, female patients with an average age of 70 years. Given that most patients are elderly with multiple comorbidities, they are poor surgical candidates. The endoscopic approach is considering to be a good alternative. As we demonstrated in our case, these patients can be successfully managed endoscopically with lithotripsy despite the low success rate that was reported in the literature. Endoscopic treatment is effective and safer and should be considered as a first line option.

2156 Innovative Use of Linear EUS

INTRODUCTION: Therapeutic echoendoscopic ultrasonography (EUS) is vital in the diagnosis, staging, and tissue acquisition of gastrointestinal (GI) malignancies. However, its use is typically limited to upper GI tract and rectum due to limited visualization and instrument length. We present a case of evaluating an extraluminal lesion adjacent to the distal small bowel, utilizing a linear echoendoscope. CASE DESCRIPTION/METHODS: 65 year old male with a history of cecal perforation in the setting of ischemic colitis (no pathologic evidence of malignancy), status post right hemicolectomy, COPD, DM and CHF was admitted with right sided abdominal pain without change in bowel habits. CT scan revealed a mass in the mid abdomen. The mass appeared inseparable from the small bowel (ileum) just proximal to the ileocolic anastomosis; however, it was unclear if the mass was extraluminal or invading the lumen. Colonoscopy was performed and there was no evidence of an intraluminal mass. Interventional radiology was contacted for biopsy of the mass, however, there was no safe window for biopsy. GI was re-consulted and a decision was made to attempt an EUS with fine needle biopsy (FNB) in order to avoid diagnostic laparoscopy. Ileum was intubated with a pediatric colonoscope and a 0.035 inch guidewire was advanced into the small bowel. Two endoclips were placed proximal to the ileocolic anastomosis for fluoroscopic guidance. The colonoscope was then exchanged for a linear echoendoscope which was advanced alongside the guidewire with an inflated forward balloon using endoscopic and fluoroscopic guidance. The mass was identified and FNB was performed. Cytology revealed atypical lymphoid cells consistent with high grade diffuse large B cell lymphoma. DISCUSSION: Linear echoendoscope is often used for evaluation of distal colonic lesions. Traditionally the miniprobe is used for diagnosis of lesions not reachable with a linear endoscope, but lacks the ability for tissue acquisition. Recently, a forward viewing echoendoscope has been developed however it is not yet widely available. We describe a case of an innovative use of linear echoendoscope in the proximal colon/distal small bowel, sparing a more invasive surgical procedure. In addition, we describe a novel use a forward balloon as a safety mechanism for advancing a side viewing endoscope in areas of limited visualization.

2648 A Case of Amebiasis in a Patient With Familial Hypertriglyceridemia Complicated by Recurrent Pancreatitis

INTRODUCTION: Amebiasis disproportionately affects people in developing countries because poor sanitation conditions increase the risk for pathogen acquisition. In the United States, individuals who travel to endemic areas and men who have sex with men are two groups at higher risk of exposure. The following case highlights the importance of exposure history and avoiding anchoring bias. The patient’s constellation of symptoms could be explained by his history of chronic pancreatitis and pancreatic insufficiency, but upon further investigation he was also found have an infective enteritis. CASE DESCRIPTION/METHODS: A 44-year-old man with a past medical history significant for type 2 diabetes mellitus, idiopathic small fiber neuropathy, and familial hypertriglyceridemia complicated by recurrent pancreatitis was admitted for recurrent symptoms of nausea, vomiting, non-bloody diarrhea, and abdominal pain. Within the previous year, the patient had a PEG-J tube placement for nutritional support in the setting of severe pancreatitis complicated by acute fluid collections. On arrival to the emergency department, he was tachycardic and labs revealed a leukocytosis of 18 × 103 µL, lipase of 510 U/L, and normal LFTs. The CT scan showed a stable pancreatic pseudocyst and no suggestion of acute pancreatitis. Imaging did reveal mild thickening and dilated loops of small bowel consistent with enteritis in the left mid and left lower abdomen. Stool pathogen panel sent during previous admission had returned positive for Entamoeba histolytica (E. histolytica). The patient endorsed drinking well water from his backyard and using it to flush his PEG-J tube. DISCUSSION: The majority of amebiasis cases are asymptomatic, however 10% are associated with significant morbidity and mortality. E. histolytica is one of four species of intestinal amebae and the one related most to symptomatic disease. Malnutrition, which was present in our patient, is a risk factor for severe disease. Studies have shown that interaction between the host’s intestinal flora and E. histolytica may influence pathogenic behavior. Our patient's treatment regimen consisted of metronidazole, which is active against the trophozoite stage, and paromomycin, which eliminates intraluminal cysts. His source of exposure was likely the well water which was uncovered through a detailed exposure history.

2650 Severe Celiac Disease Presenting With Intussusception Without Lead-Point in an Adult Male

INTRODUCTION: Adult celiac disease is an autoimmune disorder that usually presents with abdominal pain and diarrhea. We present the case of an adult man who presents with chronic diarrhea and intussusception, who was diagnosed with severe celiac disease. CASE DESCRIPTION/METHODS: 38 year old male with history of depression, presents with three months of abdominal pain and intermittent watery diarrhea, associated with thirty-pound weight loss, fatigue, nausea, diffuse joint stiffness and mild swelling, and tingling and numbness that started two weeks prior. Physical exam was remarkable for thin body habitus, hyperactive bowel sounds and diffuse abdominal tenderness with guarding. Laboratory testing was significant for microcytic anemia and INR 2.7, work up for infectious causes of diarrhea was negative. Liver and renal function tests were normal. CT of the abdomen showed fluid filled colon as well as entero-enteric intussusception of approximately 10 cm in left mid abdomen. Further investigation included tissue transglutaminase (TTG) antibodies of more than 100 U/mL and IgA 227. Colonoscopy with random biopsies was performed, pathology revealed partial villous atrophy negative for increased intraepithelial lymphocytes, suggestive of celiac disease. Patient was diagnosed with severe celiac disease, associated with multiple vitamin deficiencies secondary to malabsorption and peripheral neuropathy. Patient was managed conservatively and eventually discharged with follow up of Gastroenterology and Rheumatology practices. DISCUSSION: Intussusception is well described in patients with previously diagnosed celiac disease, in which small intestinal lymphoma or adenocarcinoma may represent the “lead point” causing the intussusception. Much rarely seen is intussusception as the presenting symptom of previously undiagnosed celiac disease, particularly in the absence of a lead point. Theories of its development include presence of flaccid, dilated small bowel, fold abnormalities, lymphadenopathies and fluid excess. Intussusception in celiac disease is often multiple, transient and repetitive, so surgical intervention should be avoided. In our case, the presence of intussusception without a lead point was suggestive of celiac disease, confirmed by serologic and histologic testing. Intussusception without a lead point should prompt investigation for celiac disease as it may represent initial presentation, in order to avoid unnecessary surgical intervention.

Radiographic and ultrasonographic findings in a dog with emphysematous pyometra

BackgroundEmphysematous pyometra is a rare canine disease characterized by gas-forming bacteria infecting the uterus and causing an accumulation of both gas and infectious exudate in the uterine lumen. While radiological features of emphysematous pyometra have been previously described in dogs, the ultrasonographic appearance has not been reported.Case presentationA 7-year-old intact female Labrador Retriever was presented because of a 1 day history of vomiting, anorexia, mild polyuria/polydipsia and signs of fatigue. On physical examination the dog had a swollen vulva with a sparse amount of yellow discharge. Lateral and ventrodorsal radiographs showed a dilated predominantly gas-filled tubular structure located in the mid and cranial abdomen traversing from left to right and ending dorsally at the level of the 12th thoracic vertebra. A small intestinal ileus was initially suspected. Following the radiographic examination, abdominal ultrasound was performed. In the left mid and caudal abdomen there were two thin-walled gas-containing tubular structures. One had the typical layered appearance of an intestinal wall and represented the descending colon. The second structure had a similar thickness but homogenously hypoechoic wall and contained gas and echogenic fluid in the lumen. By use of several positional changes of the dog aiming to alter the location of the intraluminal gas, the second structure was traced to the right ovary cranially and the uterine body caudally, confirming that the structure was the right uterine horn. A final diagnosis of emphysematous pyometra was made.ConclusionUltrasound can be used as a non-invasive diagnostic method to differentiate between small intestinal ileus and emphysematous pyometra.

Extended-field radiotherapy for locally advanced cervical cancer

Extended-field radiotherapy for locally advanced cervical cancer

Lupus Enteritis as the Only Manifestation of Active Systemic Lupus Erythematosus

Lupus enteritis is a rare manifestation of systemic lupus erythematosus (SLE). It is a difficult diagnosis to make, especially in the absence of other symptoms related to active SLE. We present a case of a 25 year old female who presented with lupus enteritis as the sole manifestation of active SLE. A 25 year old female presented to the ED with diffuse abdominal pain, diarrhea, nausea, and vomiting for 2 days. She had a medical history of seasonal allergies. Family history was significant for SLE in her cousin. Her vital signs were normal, and physical exam revealed lower abdominal tenderness. A CT of the abdomen showed marked circumferential wall thickening and edema of the proximal and mid small bowel loops predominantly involving the submucosa (Image 1). Our main differential diagnoses were intestinal angioedema and mesenteric vein thrombosis. The mesenteric vessels were patent and without evidence of thrombosis. Infectious workup was negative. Laboratory testing for hereditary angioedema showed a normal C1 Esterase Inhibitor level and low C3 and C4 levels. Autoimmune work-up showed elevated ANA (13.6), anti-Smith antibody (ab), and anti-RNP ab (Table 1). The patient was diagnosed with SLE enteritis. She was maintained on bowel rest, given intravenous (IV) hydration, and started on methylprednisolone 60 mg IV daily. She had significant improvement of all her symptoms and was discharged on prednisone 75 mg by mouth daily. In SLE, isolated gastrointestinal activity without other organ involvement is highly unusual. Lupus enteritis presents with non-specific symptoms, making the diagnosis difficult. Nevertheless, it is important to identify this disease manifestation as the mortality among patients with SLE with acute abdominal pain is approximately 11%. Lupus enteritis causes submucosal edema of the jejunum and ileum. The classic findings on CT scan include circumferential bowel wall thickening (“target sign”), dilation of intestinal segments, and engorgement of mesenteric vessels (“comb sign”). The CT scan in our case showed the “target sign”. Given her negative work up for hereditary angioedema and her family history of lupus, we decided to test for SLE. We did not perform an upper endoscopy because it often does not contribute to diagnosis. It's important to note that while most sources advocate pulse dose steroids, we were able to achieve symptomatic control with methylprednisolone 60 mg daily.2543_A Figure 1. Ab (antibody); ANA (anti-nuclear antibodies); dsDNA (double-stranded DNA); Anti-RNP (anti-ribonucleoprotein).2543_B Figure 2. Image 1. Marked circumferential wall thickening consistent with “target sign” involving multiple loops of proximal/mid small bowel. There is predominantly submucosal thickening/edema, more predominantly in the mid abdomen. The thickened small bowel loops are minimally dilated. However, there is no transition point. There is moderate volume of ascites.

Intussusception in an Adult With Chronic Cannabis Use: A Case Report

Intussusception is a rare finding in adults presenting with abdominal pain. In the absence of obstruction, environmental factors should be investigated. Cannabinoid Hyperemesis Syndrome (CHS) and its relationship to intussusception in adults has not been established but should be considered if the clinical course matches the criteria and an obstruction has been ruled out. A recent article in The New York Times identified the syndrome as a commonly missed diagnosis that may affect an estimated 2.7 million Americans that are known to smoke marijuana. Patients present to the emergency department (ED) an average of 7 times before a diagnosis is made, expending up to $100,000 in medical resources. With the recent legalization of marijuana by many states, more patients are suspected to present with this syndrome. This case represents an example of how a delay in making a clinical diagnosis correlates to overtesting and rising medical costs. A 30-year-old female with a history of inhaled cannabis use since adolescence presented to the ED with abdominal pain, nausea, and vomiting. She has a history of multiple visits with similar symptoms in the last 3 years. Symptomatic relief at home was previously achieved with hot showers. The patient was managed for nausea and discharged home. The following day, she returned to the ED with severe abdominal pain and intractable vomiting. Abdominal CT revealed 3 jejunal intussusceptions:1 on the right and 2 on the left. Previous imaging on past presentations showed multiple intussusceptions along the small bowel, but a pathological lead point was never identified. She was admitted to the surgical unit and managed conservatively. On day 3, the abdominal pain subsided and repeat imaging showed resolution of all intussusceptions. Cannabinoid Hyperemesis Syndrome (CHS) is a phenomenon associated with long-term cannabis use. It can be diagnosed clinically by the following criteria: cannabis use, abdominal pain, nausea and vomiting, and symptom relief with hot showers and cannabis cessation. Our patient meets all of the criteria but the correlation to CHS was not previously considered, leading to repeat diagnostic testing and unnecessary hospital admission. In an economy where healthcare costs account for 17.9% of the GDP, reducing medical interventions that add low value to healthcare outcome is critical for the financial sustainability of our health systems. One solution lies in restoring the confidence of making a clinical judgment.3072_A Figure 1. Axial contrast enhanced CT scan of the abdomen showing a target-like mass in the small bowel, pathognomonic of intussusception.3072_B Figure 2. Ring-like configurations in the right and left mid abdomen showing evidence of additional intussusceptions (arrow).3072_C Figure 3. Sagittal contrast enhanced CT scan of the abdomen demonstrating a sausage-like mass, typical of a small bowel intussusception. No obstruction or lead point is identified.

Colonic atresia associated with imperforate anus in a patient with down syndrome, expect the unexpected

Abstract We are describing an extremely rare clinical case of two congenital anomalies coexist simultaneously in a full term 18 months-old girl, known down syndrome with imperforate anus. She underwent PDA closure and divided diverting colostomy at the neonatal period. She had multiple history of pediatric intensive care unit (PICU) admissions due to recurrent bronchial asthma exacerbation and aspiration pneumonia. She presented to the Emergency Department at the age of 14 months with 4 days history of abdominal pain, biliouse emesis, urine retention and scant stoma out-put. On Physical examination, the proximal stoma was patent and functioning well after saline irrigation. Palpable non tender central abdominal mass was found. Radiological investigations revealed a markedly distended rectal pouch extending up to mid abdomen, hydrocolpus was excluded. Exploratory midline laparotomy showed colonic atresia at sigmoid distal to the mucus fistula which was not noticed before. Patient is still awaiting PSARP and closure of colostomy once her general condition improves. Imperforate anus associated with colonic atresia is an extremely rare anomaly with a very few number of cases had been reported in the literature. Being aware of such coexistence might minimize the need for a second laparotomy.

Small intestinal adenomatous polyps resulting in chronic obstruction in a 3‐year‐old Quarter Horse gelding

SummaryA 3‐year‐old, Quarter Horse gelding was admitted to Kansas State University Veterinary Health Center with a primary complaint of colic. The horse had a 3‐month history of recurrent colic and progressive weight loss. On physical examination, the horse was quiet, alert and responsive. The horse's mucous membranes were pink and capillary refill time was 2 s. His rectal temperature was 37.6°C (99.6°F), heart rate was 56 beats/min and respiration rate was 16 breaths/min. Rectal palpation revealed an approximately 5 cm dilated, firm, tubular, mass traversing from left caudal abdomen to mid abdomen. Nasogastric intubation obtained 6 L net reflux. A 5 cm diameter small intestinal intraluminal mass was detected by abdominal ultrasound. Complete blood count, serum chemistry and peritoneal fluid analysis were performed and all results were unremarkable. The horse was humanely euthanised due to pain and financial constraints. Post‐mortem examination and histopathology revealed a 15 × 5 × 5 cm polyp with multiple smaller satellite polyps that obstructed the distal duodenum. Colic was considered secondary to small intestinal obstruction and luminal distension caused by the adenomatous polyps. To the authors’ knowledge, this is the first report to include ultrasound images of a small intestine adenomatous polyp that caused small intestinal obstruction and colic in a 3‐year‐old horse.

Intestinal duplication revealed by posterior reversible encephalopathy syndrome.

We report a unique case of intestinal duplication detected on posterior reversible encephalopathy syndrome (PRES) in a 13-year-old girl. She was admitted to the pediatric Emergency Department because of generalized seizures. Radiological assessment revealed a large, well-defined, thick-walled cystic lesion in the mid abdomen, suggestive of duplication cyst associated to a PRES. Exploration confirmed the diagnosis of ileal duplication cyst, and the mass was resected. The postoperative course was uneventful. Both hypertension and neurological dysfunction resolved after the mass resection. A followup brain magnetic resonance imaging was performed 9 months later and showed complete resolution of the cerebellar changes. Although extrinsic compression of the retroperitoneal structures has not been reported in the literature as a complication of duplication cyst, we strongly believe that this is the most logical and plausible hypothesis that would explain the pathogenesis of PRES in our patient.

Recurrent Voluntary Ingestion of Alkaline Batteries by a Psychiatric Patient

Introduction: Foreign body ingestion occurs in approximately 100,000 cases per year, with 80% of them occurring in children. Most foreign bodies that reach the gastrointestinal tract pass spontaneously, with 10-20% requiring endoscopic removal and less than 1% needing surgical intervention. Common foreign bodies include coins, button batteries, food impaction, magnets, and paper clips and pins. Here we present a case of a young adult admitted multiple times after ingestion of two AA batteries secondary to suicidal attempt.Figure: Colonoscopy demonstrating friable pseudomembranous colitis. Friable mucosa was noted throughout the colon up to the ascending colon.Figure: Using LowerPrep by OpenBiome, 250cc of FMT was injected continuously during withdrawal of the colonoscope.Case Presentation: 33 year old female with past medical history of bipolar disorder and schizoaffective schizophrenia presented to the hospital after ingesting two AA batteries in an attempt of suicide. This was the tenth admission with similar presentation of ingestion of alkaline batteries. Physical examination on this admission was within normal limits and the patient was in no acute distress, similar to past encounters. Initial abdominal x-ray revealed two batteries over the left upper and mid abdomen with no evidence of pneumoperitoneum or intestinal obstruction (see image 1). Gastroenterology was consulted and esophagogastroduodenoscopy (EGD) was preformed, however no batteries were seen in the stomach up until the second portion of the duodenum. There were no masses or ulcers, and the esophageal mucosa was normal with few gastric erosions in the body of the stomach. Prior EGD has revealed positive presence of batteries in the stomach as well as small bowel (see image 2). Due to inability to visual the batteries on this admission, no further management was performed - as it was believed the foreign objects likely passed into the distal small bowel and would likely pass with defecation. One day later, repeat abdominal x-ray no longer revealed batteries or any other foreign bodies in the abdomen, with no signs of obstruction or significant ileus. The patient was hemodynamically stable and doing well on the floor. She was released to a psychiatric facility thereafter. Conclusion: Foreign body ingestion, in this case two AA batteries, can be a life threatening incident that must be taken seriously and urgently managed to ensure optimal quality of life.Figure. 2: double AA batteries over the left upper and mid abdomen on most recent admission.Figure: one AA and one AAA retrieved from stomach.

Clinical Vignettes/Case Reports-Practice Management.

Anterior cutaneous nerve entrapment syndrome (ACNES) is a common cause of chronic abdominal pain that often goes undiagnosed and thus undertreated. Here we present a case of a man who was investigated extensively for ‘acute abdomen' and was found to have ACNES. A 62 year old male patient with a past medical history of coronary artery disease and GERD presented to the emergency department with complaints of recurrent abdominal pain of two months duration requiring multiple ED visits. The pain was sharp in nature, located in the left lower quadrant and associated with nausea. The patient denied any association with food or bowel movements. He denied vomiting or any changes in bowel habits. The patient had a left inguinal hernia repair 3 months prior. Vital signs were within normal limits. On physical exam, he was tender to palpation in the left lower abdomen with a clear transition line in the mid abdomen. A focal point of maximum tenderness was appreciated 2 cm distal to the left of the umbilicus. A positive Carnett's sign was elicited. All other physical exam findings were unremarkable. Laboratory work up was within normal limits. A right upper quadrant ultrasound and multiple CT scans of the abdomen showed no acute findings. Gastroenterology were consulted and a triamcinolone plus lidocaine injection was given to the point of maximum tenderness with instantaneous resolution of symptoms. Anterior cutaneous nerve entrapment syndrome (ACNES) is a commonly under-diagnosed and under treated cause of severe abdominal pain. The lower thoracoabdominal nerve roots become entrapped often at the lateral border of the rectus abdominis muscle causing pain. It is believed that the patient's hernia repair surgery was the culprit behind his presentation. Patients typically have pain on palpation of one site at the lateral border of the rectus abdominis muscle and a positive Carnett's sign. A positive Carnett's sign is appreciated if the pain increases or remains the same with the examiner's finger on the point of maximum pain as the patient raises both legs. A positive sign indicates abdominal wall pain. A trigger point injection resolving the symptoms may then confirm the diagnosis. Therefore, with high index of suspicion, it would save not only the patient from multiple unnecessary hospital visits, but also decrease hospital spending on unnecessarily work up like CT scans, ultrasounds and laboratory testing.

A Case Report of Lymphoepithelial Cyst: The Great Imitator of Pancreatic Malignancy

There is a variety of pancreatic cysts which can be divided into neoplastic and non-neoplastic. Excluding inflammatory fluid collections secondary to acute pancreatitis, non-neoplastic pancreatic cysts (NNPC) are uncommon. Here we describe an extremely rare case of a female patient presenting with lymphoepithelial cyst (LEC) which primarily occur in males. Patient is a 61 year old Dominican female with past medical history of hypertension and dyslipidemia who presented to our institution complaining of 1 month history of epigastric pain radiating to her back and 20 pounds weight loss. She did not pay attention to this at first, however, pain got progressively worse and she went to see a primary care physician who scheduled patient for imaging and EGD. As pain increased to a point that she was unable to sleep at night, patient's daughter decided to take her to emergency department prior to further evaluation. She denied any tobacco or alcohol use. CT of abdomen/pelvis with PO/IV contrast was obtained and found a 5.1 cm focal lesion within body and tail of pancreas with mild peripancreatic stranding without evidence of a fluid collection, and atrophy of distal tail with multiple small cysts which may represent dilatation of pancreatic duct. Abdominal MRI with and without contrast was consequently obtained which showed a 5.1 x 2.1 x 4.0 cm heterogeneous cystic/necrotic mass within body of pancreas; ductal dilatation in tail up to 3.8 mm; and abutment of splenic artery and possible occlusion of splenic vein resulting in varices within left upper and mid abdomen. Labs were unremarkable except for CA19-9 of 197 and CEA of 6.9. EUS with FNA was then performed which identified a 5.0 x 4.0 x 3.5 cm hypoechoic, heterogeneous lesion in body and tail of the pancreas. Rapid on-site evaluation was performed with finding suspicious for LEC. Subsequent smears and cell block revealed numerous lymphocytes and squamous cells favoring lymphoepithelial cyst. Patient was referred to hepatobiliary surgery for further evaluation and scheduled for open distal pancreatectomy. EUS with FNA is the modality of choice for diagnosis of LECs and other NNPCs. Although high tumor markers have been reported in LECs, there is no literature describing malignant transformation. Therefore, it is imperative to correctly characterize cystic pancreatic lesions, as NNPCs can mimic neoplastic process but would only require surgical treatment if symptomatic.FigureFigure

Recurrent Jejunal Intussusception From Heterotopic Pancreas

Introduction Heterotopic or ectopic pancreas is usually asymptomatic. We present a unique case of heterotopic pancreas of the jejunum causing recurrent jejunal intussusception. Case description A 39-year-old male presented locally with a one-year history of recurrent left mid abdominal discomfort. Prior contrast-enhanced computed tomography (Figure 1) was reviewed and showed two areas of jejunal intussusception (arrows). Subsequent diagnostic laparoscopy done at his local hospital was unrevealing. Given ongoing recurrent pain, he came for further evaluation. On examination at our institution, the patient did have pain to palpation in the left mid abdomen without an appreciated mass. Laboratory evaluation revealed a normal complete blood count, liver test and chromogranin A. Capsule endoscopy did visualize a submucosal jejunal lesion. Double balloon enteroscopy showed a 3-centimeter distal jejunal submucosal umbilicated mass (Figure 2). The biopsy of the lesion showed normal jejunal mucosa without dysplasia. Small bowel resection was recommended for definitive diagnosis and to treat the probable recurrent intussusception. Pathologically, a solid 1.2 x 0.8 x 0.6 cm submucosal mass was found. The biopsy result showed benign jejunum with pancreatic glands and ducts extending from the mucosal surface to the muscularis propria consistent with heterotopic pancreatic glands (Figure 3, HE, x10). He has had no further episode following the surgery.FigureFigureFigureDiscussion We present a rare case of heterotopic pancreas of the jejunum causing recurrent jejunal intussusception. Heterotopic (or ectopic) pancreas is a rare congenital anomaly defined as pancreatic tissue that lacks anatomical or vascular communication with the normal body of the pancreas. It is usually found in the stomach, duodenum and jejunum. It generally has a diameter of 1-4 cm and is commonly submucosal in nature. Heterotopic pancreas is commonly asymptomatic but can cause pancreatitis, abscess, pseudocyst, malignant transformation, or local complications such as obstruction or intussusception. The diagnosis of this lesion can be challenging. Endoscopic features include umbilication and duct opening, but these findings are non-specific. Endoscopic biopsies are generally superficial and not diagnostic. As the diagnosis is challenging, surgical or endoscopic excision is recommended for both diagnosis and treatment.

Transient Intussusception

Intussusception is the invagination of a bowel segment into the contiguous intestinal tract. It can be further classified according to their location as enteroenteric, colocolonic and enterocolonic, being ileocecal the most common. On CT images, we can recognize three different patterns like target, reniform and sausage shaped. This is a 33-year-old man with a PMH of heroin abuse. Patient was brought to the ER complaining of a right lower abdominal pain. This pain started 2 hours prior arrival to ER and it was described as sharp, stabbing, and radiating to the entire abdomen with associated nausea and vomiting. He denied Any fever. Vital signs showed a BP of 139/80 mmHg, pulse of 80 bpm, RR of 20 and temperature of 99.4 F. On physical exam, the abdomen was soft with tenderness to palpation of RLQ but without rebound. A CT abdomen was done diagnosing short segment of jejunal-jejunal intussusception in the left mid abdomen. Fifteen hours later a repeated CT showed a resolved intussusception, after which the patient underwent a diagnostic laparoscopy where a normal appearing jejunum and ileum without was seen, without any evidence of intussusception. There were no bleeding points or tumors noted on the external surface of both the jejunum and ileum and the appendix appeared grossly normal. Procedure was terminated and the patient was discharged, without any further workup. It is interesting to mention that the mechanism of any intussusception seems to be related to a bowel lesion that serves as a lead point. Although rare, cases of transient episodes have been seen in patients with celiac or Crohn's disease. Unfortunately, our patient was discharge without any further evaluation of the etiology of this episode. Moreover, other diagnostic methods like intraoperative enteroscopy, push-enteroscopy or MR enterography could have been appropriate in this case to find any intraluminal tumors and/or inflammatory process. We report this case to encourage physicians to perform a deeper assessment of the etiology of an episode of intussusception, regardless of its transient nature, since patients can have reoccurring events in the future.Figure: CT abdomen at admission showing intussusception.Figure: CT abdomen- coronal view at admision: intussusception measuring about 5.5 cm in length in the left abdomen.Figure: CT abdomen 15 hours after: where previously seen intussusception has resolved.

Non-communicating small intestinal duplication in a dog: a case report

Enteric duplication is rare in dogs. Here, we report the rarest form of duplication in which two segments are parallel and share a wall for most of their lengths. A nine-year-old spayed female Yorkshire terrier was referred to the Veterinary Medical Teaching Hospital at Gyeongsang National University due to anorexia and diarrhoea. Physical examination, haematological examination, radiography, and ultrasonography were performed. On physical examination, dry, pale mucous membrane was identified. Moderate anaemia with decreased packed cell volume was detected in complete blood count. Serum urea nitrogen and creatinine levels were mildly increased. Radiographic images revealed no significant findings. On ultrasonographic examination, a multi-layered appearance of a focal small intestinal segment was identified in the left mid abdomen. Following the lesion, it was divided into two small intestinal segments. Based on imaging findings, intussusceptions or enteric duplication were suspected. To resect the abnormal small intestinal segment, enterectomy was performed. Follow-up was not performed because the patient expired during the postoperative recovery time. The histopathological diagnosis was non-communicating small intestinal duplication. Non-communicating intestinal duplication is related to embryologic abnormalities and is usually concurrent with other anomalies such as vertebral malformations and urogenital duplications. However, this case had no other anomalies associated with the malformation of the intestine.

Simulation of Tracer Dose Reduction in 18F-FDG PET/MRI: Effects on Oncologic Reading, Image Quality, and Artifacts.

The aim of our study was to evaluate the effect of stepwise-reduced doses on objective and subjective image parameters and on oncologic readings in whole-body 18F-FDG PET/MRI. Methods: We retrospectively simulated the stepwise reduction of 18F-FDG doses of 19 patients (mean age ± SD, 50.9 ± 11.7 y; mean body mass index ± SD, 22.8 ± 3.2 kg/m2) who received a whole-body PET/MRI examination from 3 to 0.5 MBq/kg of body weight (kgBW) in intervals of 0.25. Objective imaging parameters were assessed by measuring the SUV and coefficient of variation in different regions (aorta, liver, spleen, kidney, small bowel, lumbar vertebra, psoas muscle, urinary bladder) as well as the noise-equivalent counting rates in each bed position. Subjective image quality was evaluated with a masked reading of each simulated PET compared with the dose of 2 MBq/kgBW. Oncologic reading was performed first according to PERCIST in each dose and second by defining malignant lesions in doses of 2 MBq/kgBW and the maximum dose image (gold standard). The diagnostic confidence of each lesion was measured using a Likert scale. Results: With decreasing doses, regions in the mid abdomen showed a stronger decrease of SUVmean and noise-equivalent counting rates than regions in the upper abdomen (SUVmean, -45% and -15% on average in the small bowel and the liver, respectively). The coefficient of variation showed a nonlinear increase, pronounced below 1.5 MBq/kgBW. Subjective image quality was stable over a range between 1.25 and 2.75 MBq/kgBW compared with 2 MBq/kgBW. However, large photopenic areas in the mid abdomen were observed in 2 patients. In the PERCIST reading, target lesions were above the liver threshold with a stable SUVpeak in all cases down to 2 MBq/kgBW. Eighty-six of 90 lesions were identified correctly with a dose of 2 MBq/kgBW; Likert scores did not differ significantly. Conclusion: A reduction of doses in 18F-FDG PET/MRI might be possible down to 2 MBq/kgBW in oncologic whole-body examinations. The image quality in the mid abdomen seems to be more affected by lower doses than in the upper abdomen, and in single cases large photopenic areas can occur. Therefore, we do not recommend reducing doses below 3 MBq/kgBW in adults at this time.

Lymphangioma torsion of the omentum in a child: A case report

Abstract Lymphangiomas rarely present as intra-abdominal masses. These lymphatic malformations can arise in the mesentery, retroperitoneum and omentum. Omental cysts are usually benign and asymptomatic. We present an omental cyst with torsion in a pediatric patient presenting with abdominal pain and vomiting a few days before admission to our institution. Physical examination shows soft globular abdomen with a palpable tender mass in the mid abdomen. This patient was worked-up with an initial pre-op CT scan with IV contrast of the abdomen showing multiple intraabdominal cystic masses. Patient underwent laparotomy and complete excision of the omental cystic masses. Surgery mandates complete surgical excision to prevent recurrence. Patient was discharged without any untoward post-operative complications.