Nonspecific Abdominal Symptoms Research Articles

Intestinal ischemia: A rare and less common complication after laparoscopic cholecystectomy-A case report and literature review.

Patients with a history of persistent mesenteric ischemia should not undergo laparoscopy. Mesenteric ischemia must be kept in mind for patients who develop nonspecific abdominal symptoms following laparoscopic surgeries. During laparoscopic cholecystectomy (LC), the rise in Intra-Abdominal Pressure due to carbon dioxide insufflation can reduce blood flow through splanchnic vessels, potentially leading to intestinal ischemia. A 72-year-old woman with a history of diabetes, hypertension, ischemic heart disease, and hyperlipidemia underwent LC. She was discharged but readmitted 4 days later due to peritonitis. Ischemic jejunum loops were found during surgery.

Primary pancreatic hydatid cyst; typical radiological signs: A case report

Pancreatic hydatid cysts are rare, especially in pediatric populations, and their diagnosis presents a remarkable challenge because of the non-specific clinical presentation and the limitations of available diagnostic tools, particularly in resource-limited settings. Our case highlights the importance of maintaining a high index of suspicion for hydatid disease, even in pediatric patients presenting with non-specific abdominal symptoms, particularly in rural regions, where diagnostic resources may be limited. Early recognition and accurate diagnosis are crucial for guiding appropriate therapeutic interventions and preventing potential complications associated with this rare but clinically significant entity.

Isolated Partial Dorsal Pancreatic Agenesis Detected Incidentally by Contrast-enhanced Computed Tomography

Agenesis of the dorsal pancreas is a rare congenital pancreatic malformation because of failure in the development of the dorsal bud of the pancreas resulting in absent corpus and cauda of pancreas. Patients with agenesis of the dorsal pancreas often present with non-specific abdominal symptoms and very often it is an incidental finding. Here, we report the contrast enhanced imaging details of this rare entity in a 63 year old woman that was detected incidentally on computed tomography and there was no other co-existing anomaly.

Predictive value of abnormal blood tests for detecting cancer in primary care patients with nonspecific abdominal symptoms: A population-based cohort study of 477,870 patients in England.

Identifying patients presenting with nonspecific abdominal symptoms who have underlying cancer is a challenge. Common blood tests are widely used to investigate these symptoms in primary care, but their predictive value for detecting cancer in this context is unknown. We quantify the predictive value of 19 abnormal blood test results for detecting underlying cancer in patients presenting with 2 nonspecific abdominal symptoms. Using data from the UK Clinical Practice Research Datalink (CPRD) linked to the National Cancer Registry, Hospital Episode Statistics and Index of Multiple Deprivation, we conducted a population-based cohort study of patients aged ≥30 presenting to English general practice with abdominal pain or bloating between January 2007 and October 2016. Positive and negative predictive values (PPV and NPV), sensitivity, and specificity for cancer diagnosis (overall and by cancer site) were calculated for 19 abnormal blood test results co-occurring in primary care within 3 months of abdominal pain or bloating presentations. A total of 9,427/425,549 (2.2%) patients with abdominal pain and 1,148/52,321 (2.2%) with abdominal bloating were diagnosed with cancer within 12 months post-presentation. For both symptoms, in both males and females aged ≥60, the PPV for cancer exceeded the 3% risk threshold used by the UK National Institute for Health and Care Excellence for recommending urgent specialist cancer referral. Concurrent blood tests were performed in two thirds of all patients (64% with abdominal pain and 70% with bloating). In patients aged 30 to 59, several blood abnormalities updated a patient's cancer risk to above the 3% threshold: For example, in females aged 50 to 59 with abdominal bloating, pre-blood test cancer risk of 1.6% increased to: 10% with raised ferritin, 9% with low albumin, 8% with raised platelets, 6% with raised inflammatory markers, and 4% with anaemia. Compared to risk assessment solely based on presenting symptom, age and sex, for every 1,000 patients with abdominal bloating, assessment incorporating information from blood test results would result in 63 additional urgent suspected cancer referrals and would identify 3 extra cancer patients through this route (a 16% relative increase in cancer diagnosis yield). Study limitations include reliance on completeness of coding of symptoms in primary care records and possible variation in PPVs if extrapolated to healthcare settings with higher or lower rates of blood test use. In patients consulting with nonspecific abdominal symptoms, the assessment of cancer risk based on symptoms, age and sex alone can be substantially enhanced by considering additional information from common blood test results. Male and female patients aged ≥60 presenting to primary care with abdominal pain or bloating warrant consideration for urgent cancer referral or investigation. Further cancer assessment should also be considered in patients aged 30 to 59 with concurrent blood test abnormalities. This approach can detect additional patients with underlying cancer through expedited referral routes and can guide decisions on specialist referrals and investigation strategies for different cancer sites.

Surgical management of a rare giant sacral meningocele in a child

IntroductionAnterior sacral meningocele is a rare congenital disorder, occurring isolated or in syndromic disease. Case reportA 15-year-old patient who complained of abdominal pain and urinary dysfunction was managed surgically. Imaging diagnosed a giant presacral meningocele and agenesis of the coccyx. DiscussionThe presentation of sacral meningocele can be poorly symptomatic, which is why some patients are diagnosed late. Sometimes, diagnosis is suggested by non-specific abdominal symptoms or complications. Abdominal-pelvic radiological examination and lumbar spine MRI are essential, and treatment must be surgical. There are several surgical approaches, but currently no consensus. ConclusionAn unusual huge presacral cystic mass in a young patient may be isolated or part of a syndrome, and can be asymptomatic for a long time, leading to late diagnosis. The surgical approach should be based on multidisciplinary discussion. We operated on a giant anterior sacral meningocele in a child using a posterior approach, with a satisfactory result.

Point-of-Care Ultrasound for Pediatric Vaginal Obstruction in the Emergency Department: A Case Series.

Point-of-care ultrasound can be an effective tool to facilitate the evaluation of abdominal and pelvic pain in children. We present a series of 3 pediatric patients with nonspecific abdominal and pelvic symptoms in whom point-of-care ultrasound expedited diagnosis, guided decision-making, prompted subspecialist consultation, and led to definitive management of vaginal obstruction.

Gastrointestinal stromal tumors in fine-needle aspiration biopsies.

Gastrointestinal stromal tumors (GISTs), although rare, are the most common mesenchymal neoplasms of the gastrointestinal tract. Their potential for malignancy underscores the significance of identifying them through cytomorphologic findings and pertinent immunohistochemical markers. GISTs can emerge anywhere along the gastrointestinal tract with a predilection for the stomach. The clinical manifestations vary from nonspecific abdominal symptoms to incidental discovery during diagnostic interventions for unrelated signs and symptoms. Cytologically, GIST aspirates contain spindle or epithelioid cells with immunoreactivity for CD117/c-KIT, DOG-1, and CD34. Molecularly, KIT or PDGFRA mutations are prevalent, guiding targeted therapy with tyrosine kinase inhibitors. Distinct subtypes like succinate dehydrogenase-deficient GISTs pose challenges, often affecting younger individuals and displaying unique features. Histologically, GISTs are graded by mitotic rates, aiding prognostication. Distinguishing GISTs from similar entities is pivotal, necessitating attention to their immunostaining patterns for making an accurate diagnosis and molecular alterations for effectively planning treatment. Common differential diagnoses include leiomyoma, schwannoma, and solitary fibrous tumor. This article presents a classic GIST case and showcases relatively simple diagnostic clues for identifying similar lesions that may occur in diverse locations.

Ascites Caused by Intestinal Anisakiasis: A Case Report and Literature Review.

Anisakiasis is a parasitic infection affecting the human gastrointestinal tract. It is caused by the consumption of contaminated, raw or inadequately cooked fish or squid, which is typically used for making sushi and sashimi. Most cases involve gastric anisakiasis, whereas intestinal anisakiasis is rare. This report describes the case of a 63-year-old Japanese woman with a history of raw fish consumption who presented with acute-onset abdominal pain and vomiting. Abdominal computed tomography (CT) demonstrated thickened small bowel loops and ascites on the liver surface. The patient was admitted for supportive care. On the second day of hospitalization, contrast-enhanced abdominal CT revealed that the ascites had moved from the liver surface to the pouch of Douglas. On the fifth day of hospitalization, the patient was discharged with a substantial improvement in abdominal pain. Five days after the discharge, her eosinophil count was elevated, and parasitic disease was therefore suspected. Anti-Anisakis IgG/A and IgE (RAST) antibody levels were elevated, confirming the diagnosis of intestinal anisakiasis. A review of 51 reported cases of intestinal anisakiasis suggests that the presence of ascites and measurement of anti-Anisakis antibody titers are helpful for diagnosis in cases presenting with nonspecific abdominal symptoms after consumption of raw or undercooked fish.

Coeliac lymph node abscess: A case report of a rare manifestation of extrapulmonary tuberculosis

Tuberculosis is a leading cause of death worldwide, especially in developing countries. It can affect any site in the body and have a myriad of presentations making diagnosis challenging. Tuberculous lymphadenitis in the abdomen is rare. We present a case of a 42-year-old man who presented with non-specific abdominal symptoms and was found to have an intraabdominal abscess on computed tomography scan of the abdomen. Endoscopic ultrasound-guided aspiration was performed, and tuberculosis was confirmed. This case highlights the importance of having a high clinical suspicion of tuberculosis even with vague symptoms in tuberculosis endemic countries. This would prevent unnecessary surgery as tuberculosis is responsive to anti-tuberculosis drugs.

Parahiatal hernia: A rare type of hernia and the answer to an anatomical challenge

Parahiatal hernias are rare. They are difficult to diagnose preoperatively, as the clinical symptoms may be similar to hiatal and paraoesophageal hernias. Here, we report two cases of parahiatal hernia that were preoperatively diagnosed and successfully repaired laparoscopically; using the particular anatomic characteristics of this hernia, we also review the controversial oesophageal hiatal anatomy, as the surgical community often refers to the left bundle of the right crus as the left crus. There is no consensus on the indication or surgical technique to repair them. The first case is a 59-year-old woman with non-specific abdominal symptoms, in whom the preoperative gastroscopy and computed tomography (CT) raised the suspicion for parahiatal hernia. The second case is a 68-year-old woman who presented to the emergency department with abdominal distention and nausea, but no vomiting. Preoperative CT raised the suspicion of an incarcerated parahiatal hernia. Both patients underwent laparoscopic repair of the parahiatal hernia and a Toupet fundoplication. They had an uneventful postoperative course. After more than 4 years of follow-up, they are both asymptomatic. Parahiatal hernias are a rare form of diaphragmatic hernia that occur through a diaphragmatic defect lateral to an anatomically normal oesophageal hiatus, with herniation of contents between the left portion of the right crus and the left crus. Up to five different anatomical variations have been described. The knowledge of these anatomical variations has an impact on the type of surgical repair that will need to be performed if a parahiatal hernia is found.

Pancreatic ductal adenocarcinoma (intestinal-type differentiation) presenting as ovarian metastases: A case report

Introduction: Metastasis of pancreatic adenocarcinoma to the ovaries is uncommon and can clinically present similarly to primary ovarian disease, presenting challenges for diagnosis. Immunohistochemical staining is typically useful in distinguishing ovarian primaries from ovarian metastasis. A newer and rarer variant of pancreatic adenocarcinoma, that with intestinal-type differentiation, has not previously been reported as metastasizing to the ovary. Its diagnosis is particularly difficult due to the overlap in staining patterns with primary ovarian neoplasms. Case Report: This case report presents the case of a 60-year-old female who presented with non-specific abdominal symptoms and was found to have a large adnexal mass. Imaging showed additional lesions in the peritoneum, pancreas, and liver. She underwent biopsy with morphology and immunohistochemical staining consistent with pancreatic ductal adenocarcinoma with intestinal-type differentiation. She was started on FOLFIRINOX therapy but ultimately opted to pursue comfort care due to disease progression. Conclusion: Although rare, with this being the first report of this disease course to our knowledge, clinicians should be aware of this possibility, as it impacts choice of treatment.

Schistosomiasis Manifesting as a Rectocolonic Calcification: A Case Report

Schistosomiasis is a rare disease with a common intestinal involvement. However, recto-colonic calcifications associated with Schistosoma have rarely been reported, especially in young people; this is the first case with the following presentation. We describe the case of an 18-year-old Moroccan woman who presented with nonspecific abdominal symptoms. Her biochemical profile was normal in addition to the results of her stool and urine tests. An abdominal computed tomography showed multiple Intraluminal calcified structures m, creating a pseudo-mass appearance This unusual case will give us the opportunity to discuss schistosomiasis, its occurrence in colon polyps, clinical significance and the various means of management.

Idiopathic myointimal hyperplasia: An unusual cause of colonic ischemia

Introduction: Ischemic colitis is a commonly encountered surgical condition with a variety of causes, including atrial fibrillation, atherosclerosis, hypoperfusion, vasculitis, and rarely drug causes such as methamphetamines. Case Report: Here we describe the case of a 47-year-old male who presented with non-specific abdominal symptoms. He was initially treated for severe ulcerative colitis (UC), before biopsies were re-reviewed and specimens showed changes pathognomic for idiopathic myointimal hyperplasia of the mesenteric veins (IMHMV). He underwent surgical resection of affected segments and recovered well. Conclusion: This case illustrates a rare diagnosis presenting with common symptoms and the importance of considering this diagnosis in patients not responding to usual treatment.

Abstract 6752: Patient (pt) characteristics, diagnostic journey, and cancer enrichment among pts with nonspecific signs and/or symptoms (s/sx) in the US community oncology setting: a real-world retrospective study

Abstract Of the >1.6 million people diagnosed with cancer in the US each year, >60% are diagnosed after symptomatic presentation, including nonspecific s/sx. These nonspecific s/sx may cause pts to undergo unnecessary diagnostic evaluation while the possibility of cancer and search for its origin is explored, causing delayed treatment and poor outcomes. Additionally, pts who do not have cancer are often subjected to various undirected/misdirected procedures due to initial cancer suspicion. Our objective was to examine pt characteristics, diagnostic journey, and cancer incidence of pts with nonspecific s/sx within The US Oncology Network. This retrospective observational cohort study included pts aged ≥40 with ≥1 of the following nonspecific s/sx in their problem list at their first visit within The US Oncology Network (index date) during the identification period from 1/1/2016 to 12/31/2020: anemia, venous thromboembolism, general malaise, weight loss, nonspecific abdominal symptoms, new and unexplained breathlessness, unexplained worsening pain, and abnormal lab test results. Pts were excluded if diagnosed with any cancer (except basal cell carcinoma and squamous cell carcinoma skin cancer) within 3 years prior to or on index date. Pts were followed longitudinally with data from electronic health records for initial cancer diagnosis (dx), death, end of study observation period, or 12 months, whichever occurred first. Demographic and clinical characteristics were assessed descriptively. 103,984 pts were identified. The median age was 65.7, 64% were female, 65% were White, 41% were obese, 47% were never smokers, and 48% were from a southern practice region. 6,774/103,984 pts (7%) were diagnosed with cancer and 6,537/6,774 (97%) with 1 primary cancer: 3,825/6,537 (59%) were diagnosed with a hematologic malignancy and 2,712/6,537 (41%) with a solid tumor cancer. Among pts diagnosed with primary solid tumors, 31% had gastrointestinal, 15% genitourinary, 15% respiratory, 13% breast, and 11% gynecologic cancer. Among pts diagnosed with cancer, median time to cancer dx after being referred to secondary care within The US Oncology Network with nonspecific s/sx was >5 wks (solid: >7 wks; hematologic: >4 wks); by 17 and 34 wks, 75% and 90% of pts received a cancer dx, respectively. Within this population of pts most frequently presenting with nonspecific hematologic s/sx and subsequent cancer dx, 40% were diagnosed with solid tumor cancers within 1 year. This speaks to the unmet need for more tools such as a multi-cancer detection test that could aid in detection of multiple cancers and faster diagnostic resolution of nonspecific s/sx. Given the impact of delayed cancer dx and timely treatment on outcomes, such a test could potentially substantially improve cancer care and diagnostic evaluations. Citation Format: Christopher Benton, Ding He, Karen Todoroff, Marie V. Coignet, Ying Luan, Kathryn N. Kurtzman, Ira Zackon. Patient (pt) characteristics, diagnostic journey, and cancer enrichment among pts with nonspecific signs and/or symptoms (s/sx) in the US community oncology setting: a real-world retrospective study. [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2023; Part 1 (Regular and Invited Abstracts); 2023 Apr 14-19; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2023;83(7_Suppl):Abstract nr 6752.

Impact of endoscopic ultrasound-guided radiofrequency ablation in managing pancreatic malignancy.

Pancreatic malignancy is still the most lethal gastrointestinal malignancy. It has a very poor prognosis with low survival rate. Surgery is still the main treatment option for pancreatic malignancy. Most patients already have locally advanced and even late stage disease due to non-specific abdominal symptoms. Even though some cases are still suitable for surgical treatment, due to its aggressiveness adjuvant chemotherapy is becoming the standard treatment for controlling the disease. Radiofrequency ablation (RFA) is a thermal therapy that has been used as one of the standard treatments for liver malignancy. It can also be performed intraoperatively. There are several reports on percutaneous RFA treatment for pancreatic malignancy using transabdominal ultrasound and guided by computed tomography scan. However, due to its anatomical location and the risk of high radiation exposure, these methods seem to be very limited. Endoscopic ultrasound (EUS) has been widely used for pancreatic abnormality evaluation due to its ability to detect more accurately, especially small pancreatic lesions, compared to other imaging modalities. By the EUS approach, it is easier to achieve good visualization of tumor ablation and necrosis as the echoendoscope position is closer to the tumor area. Based on studies and a recent meta-analysis, EUS-guided RFA is a promising treatment approach for most pancreatic malignancy cases, but most studies only collected data from a small sample size. Larger studies are needed before clinical recommendations can be made.

S3509 A Case of Diffuse Malignant Peritoneal Mesothelioma

Introduction: Malignant Mesothelioma occurs most commonly in the pleural space but can also occur in the peritoneum in those with an extensive history of asbestos exposure. Peritoneal mesothelioma (MPeM) is relatively rare accounting for 15% of all mesotheliomas. Most patients are asymptomatic until advanced stages but will present with nonspecific abdominal symptoms. We present a case of MPeM in a male who worked in a wire hanger factory for 20 years. Case Description/Methods: An 81-year-old Arabic male presented with nausea, vomiting, abdominal distention and diarrhea lasting three weeks. His vitals were remarkable for hypertension (192/102 mmHg), and he had diffuse abdominal tenderness without peritonitis on physical exam. CT A/P with contrast showed fluid distending the small and large bowel and mild fat stranding and wall thickness of the ascending and descending colon. Ascites was also noted. Laboratory studies revealed elevated ALT (54 unit/L) with otherwise normal AST, ALP and bilirubin. CRP (87 mg/L), ESR (30 mm/hr) and WBC’s (12.9 x10^3/mm3) were all elevated. A repeat CT A/P was suggestive of small bowel obstruction and he underwent a diagnostic laparoscopy with right hemicolectomy, ileocolonic anastomosis and omentectomy. The resected obstructing mass was diffuse MPeM, epithelioid type extensively involving the small bowel muscularis propria and submucosa and focally involving the lower mucosa of the ileocecal region (T0N0). Immunohistochemical analysis showed strong positive reactions with calretinin, CK 5/6, WT-1 and D2-40. Negative reaction was present with CK20, synaptophysin, chromogranin, and prostatic markers. He received 12 cycles of nivolumab, 7 cycles of ipilibumab and palliative radiation due to increasing tumor burden but was ultimately transferred to hospice approximately 2 years after initial diagnosis. Discussion: MPeM as the primary source of mesothelioma is uncommon. Asbestos exposure confers a lower risk of MPeM in males. Patients with MPeM are typically younger at the time of diagnosis than those with pleural involvement and are usually women. Females have prolonged survival due to less aggressive histological subtypes, such as epithelial. The 3- year survival rate for MPeM after treatment is 39% for males. Our patient was 81 years-old at time of diagnosis and was a male who was likely exposed to asbestos for over 20 years. He outlived his life expectancy given his age, gender, location of mesothelioma, etiology and histological subtype.

S3138 Primary Hepatic Angiosarcoma: A Rare Cause of Decompensated Pseudo-Cirrhosis and Acute Liver Failure

Introduction: Primary hepatic angiosarcoma (PHA) is a rare aggressive endothelial cell tumor which is seen in patients in their 60s and 70s with 3:1 male predominance. Industrial exposure to vinyl chloride, radium, chronic arsenic ingestion, anabolic steroid use, and iatrogenic exposure to thorotrast radiocontrast are some of the known etiologies for the development of PHA. Whereas, in most cases, attributable risk factors are rarely identified. Case Description/Methods: A 68-year-old male patient with NIDDM presented with chest pain and abdominal distension. Examination revealed marked ascites, abdominal tenderness, and bilateral leg edema. Labs were significant for thrombocytopenia and cholestatic pattern of liver enzymes with AST 94, ALT 47, ALP 413, T bilirubin 5.7. Paracentesis was negative for SBP or malignant cytology and was indicative of portal hypertensive ascites. Tumor marker workup was positive for CA 19-9 106.1, whereas negative for CEA 1.82, and AFP 2.7. CT A/P showed multifocal large heterogeneous enhancing lesions in the liver which were biopsied showing diffuse proliferation of abnormal vascular endothelial cells staining positive for CD34 and a diagnosis of PHA was made. With multifocal lesions, the patient was started on paclitaxel chemotherapy, which was eventually stopped with worsening liver function. The hospital course was complicated by hepatic encephalopathy and coagulopathy. The patient and the family later chose to transition to palliative therapy for comfort (Figure 1). Discussion: PHA is a rare and aggressive tumor with poor outcomes and an average survival rate of less than a year. Early diagnosis is challenging as it presents with nonspecific abdominal symptoms. With progression, PHA can present as decompensated pseudocirrhosis due to compression of liver parenchyma leading to portal hypertension. Contrast-enhanced US and CT can help in diagnosis by showing lesions characteristic of central non-enhancement and peripheral irregular enhancement in the arterial and portal phase, and complete wash-out in the late phase. A definitive diagnosis of PHA is established via histopathological analysis with immunohistochemistry staining but can make diagnosis more challenging due to the potential of associated bleeding. Surgical excision with negative surgical margins is the standard treatment for PHA which is localized and resectable. Multifocal and metastatic PHA is a radio-resistant tumor with a paucity of treatment options, however, TACE and/or salvage chemotherapy can be potentially attempted.Figure 1.: CT Abdomen pelvis showing multiple mass lesions occupying most of liver parenchyma.

S3519 A Rare Case of Epigastric Pain Caused by Duodenal Metastatic Cervical Cancer

Introduction: Cervical cancer was previously one of the most common causes of death for women in the United States but survival has since improved with the use of screening and the HPV vaccine. Metastatic cervical cancer spread to the duodenum is rare and presents a diagnostic challenge due to vague symptoms. We present a case of epigastric pain caused by invasive squamous cell cervical cancer with duodenal metastasis. Case Description/Methods: A 59-year-old female with a history of GERD and treated cervical cancer (2 years prior) and currently on pembrolizumab presented to clinic for 3 months of progressive upper abdominal pain and dyspepsia. Last upper endoscopy a year ago was normal. Physical exam was notable for epigastric tenderness without guarding. Laboratory data was remarkable for downtrending hemoglobin, normal liver function tests, normal lipase, and negative stool H pylori antigen. She was referred for EGD. A contrasted CT of the abdomen and pelvis performed revealed multiple enlarged lymph nodes of the mesentery. Upper endoscopy revealed thickened folds of the second portion of the duodenum and multiple biopsies taken of this site. It was an otherwise normal upper endoscopy. The duodenal biopsies were positive for metastatic squamous cancer of the cervix. The patient was transitioned to treatment with gemcitabine and carboplatin due to progressive disease on pembrolizumab. She unfortunately succumbed to her disease six months later. (Figure) Discussion: There is an estimated 7.5 per 100,000 new cases of cervical cancer per year with death rate of 2.2 per 100,000 in the United States. Cervical cancer is usually locally invasive and spreads by lymphatics or hematogenously with most common metastatic sites of lungs, liver, and bone. In a previous review, liver metastases was in up to 12.5% of patients but did not mention a single case of luminal disease. It is very rare for most cancers to metastasize to the gastrointestinal tract, but when present, metastasis has a predilection for the stomach and duodenum. Few case reports are available for cervical cancer metastasis to the GI tract specifically, with about 16 identified. These patients generally presented with gastrointestinal bleeding, bowel perforation, nonspecific abdominal pain or obstructive symptoms. In conclusion, duodenal metastasis of cervical cancer is rare and can be frequently missed. A high degree of suspicion can expedite referral for upper endoscopy to diagnose and allow for treatment to extend patients’ quality of life.Figure 1.: Thickened folds in the second portion of duodenum.

Asymptomatic Appendiceal Mucocele with Typical Onion Skin Sign on Ultrasound

Appendiceal mucocele is an obstructive dilatation of the appendix caused by abnormal accumulation of mucoid material. Its incidence is 0.2-0.3% of all appendectomy specimens and it does not have typical clinical features. It can mimic acute appendicitis in patients with right lower quadrant pain. Some patients have appendiceal mucocele with acute appendicitis. For this condition, 25% of cases were asymptomatic and were discovered incidentally on ultrasound examination, computed tomography, or colonoscopy due to nonspecific abdominal symptoms. Ultrasound examination or computed tomography is an important diagnostic tool for accurate preoperative diagnosis. If mucocele is treated incorrectly, pseudomyxoma peritonei may develop. The present study reports a case of a 79-year-old male with constipation. Ultrasonography showed a typical layered echogenic pattern of the appendiceal wall (onion sign or onion skin sign), which suggested appendiceal mucocele. Computed tomography showed a dilated appendix filled with low-attenuated material, indicating a pathologic diagnosis of low-grade appendiceal mucinous neoplasm.

91 Intestinal Malrotation Identified on Diagnostic Laparoscopy in a 79-Year-Old Male Presenting With Symptoms of Sub-Acute Bowel Obstruction

Abstract Congenital malrotation of the midgut in the adult population is most likely to present with non-specific abdominal symptoms that can pose a diagnostic dilemma. If left untreated the symptoms of malrotation can have a significant impact on patients’ quality of life and the condition can lead to significant morbidity and mortality. We report a case of malrotation identified in a 79-year-old male who presented with a chronic picture suggestive of sub-acute small bowel obstruction. The patient underwent thorough clinical review including CT and MRI scan which showed evidence of dilated small bowel but failed to show an underlying cause. The absence of findings with initial tests prompted the team to consider surgical investigation. Diagnostic laparoscopy identified evidence of congenital malrotation, and this was successfully treated with a Ladd’s procedure. This case adds to the evidence that malrotation is a more common finding in adults than previously thought and emphasises the importance of pursuing a definitive diagnosis when routine tests do not demonstrate sufficient cause for a patient’s symptoms.