Upper Quadrant Mass Research Articles

S2924 Ruptured GIST Mimicking Hemosuccus Pancreatitis

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are the most common non-epithelial tumors occurring in the gastrointestinal tract. Even though they are usually solid, they can appear as cystic lesions on imaging leading to a difficult diagnosis. We present a case of a GIST that was initially diagnosed as a pancreatic pseudocyst after extensive work-up. CASE DESCRIPTION/METHODS: A 61-year-old man with no past medical history presented to the ED with abdominal pain after sustaining blunt trauma to the abdomen. Abdominal CT showed a 16 cm left upper quadrant mass with central necrosis and perigastric adenopathy, but no other imaging to compare (Figure 1). During EUS evaluation a thick ring with a central cystic core was noted between the stomach and tail of pancreas. Given this location, traumatic pseudocyst was thought likely. Although the thick wall was somewhat unusual, FNA results were consistent with pseudocyst. PET scan was then performed showing a cystic mass with circumferential heterogenous and mildly increased FDG activity but no adenopathy, supporting a diagnosis of pseudocyst (Figure 2). Unfortunately, the patient was lost to follow up.Eight months later, the patient came to the ED with epigastric abdominal pain associated with black tarry stools. He was tachycardic and the abdomen was distended and tender. Laboratory workup revealed a Hb of 7.1. A CT scan showed the large heterogeneous, cystic mass suggestive of hemorrhagic content as well as ascites (Figure 3). He was admitted to ICU, received 2 units of blood and started on IV pantoprazole. A paracentesis retrieved 1.75 L of hemorrhagic fluid which led to an initial diagnosis of Hemosuccus Pancreatitis. He was not deemed a surgical candidate due to the lesion location and poor nutritional status. A percutaneous catheter was inserted for symptomatic relief and a CT guided biopsy of the wall of the cystic mass was performed. The pathology results were consistent with GIST. DISCUSSION: EUS is a valuable method for evaluation of GISTs by assessing its morphology however, due to the heterogenous appearance, diagnosis can be challenging. Moreover, FNA can yield false negative results due to inadequate amount of tissue, especially if central necrosis is present. This patient's missed diagnosis eventually led to clinical worsening where further work-up was pursued to reveal the definitive diagnosis. GISTs should be considered in your differential despite exhaustive work-up as it may evade diagnosis due to its heterogeneity in morphology and presentation.Figure 1.: Abdominal CT scan on first admission showing a 16 cm enhancing left upper quadrant mass with central necrosis and perigastric adenopathy.Figure 2.: PET scan showing a cystic mass with circumferential heterogenous and mildly increased FDG activity but no adenopathy.Figure 3.: Abdominal CT scan on second admission showing the large heterogeneous, cystic mass suggestive of hemorrhagic content.

Man With Bilateral Leg Swelling.

A 52-year-old man without known medical history presented with painful, progressive, bilateral lower extremity edema over a two-week period. An abdominal exam noted a firm left upper quadrant mass. Emergency department (ED) point-of-care ultrasound (POCUS) revealed a hyperechoic, heterogeneous structure in the inferior vena cava that was determined to represent a tumor thrombus extending from a primary renal cell carcinoma. This case demonstrates how POCUS was valuable in rapidly diagnosing this rare cause of lower extremity edema and its usefulness in directing the initial ED management of this patient.

3019 Solid Pseudopapillary Tumor of the Pancreas: A Typical Presentation in an Atypical Patient

INTRODUCTION: Solid pseudopapillary tumor (SPT) of the pancreas is a rare neoplasm. It accounts for 1% of all tumors of the pancreas. It is a benign tumor with a low malignant potential and a favorable prognosis. It typically presents in young women, and on imaging it can be seen as a large encapsulated mass with solid and cystic components. The female to male predominance is 10:1. The following case shows a typical presentation of SPT in a male patient. CASE DESCRIPTION/METHODS: A 25-year-old man from Guatemala with no medical history presented with epigastric pain, nausea, vomiting, weight loss and poor oral intake. The abdominal pain was stabbing, intermittent, and radiating to the back. Family, social and surgical history were negative. Vitals were normal. On physical examination he appeared dehydrated with epigastric tenderness and a palpable left upper quadrant mass. Labs showed normal chemistry, liver function tests, lipase, CA 19-9, CEA and CA 125. Complete blood count showed an elevated white blood cell count of 23,000. Computerized tomography revealed a 7.6 × 10 × 8 cm heterogenous mass in the distal body and tail of the pancreas, with solid, and cystic components and calcifications. The patient underwent esophagogastroduodenoscopy (EGD) and endoscopic ultrasound with fine needle aspiration (FNA) of the mass. EGD showed a small non-bleeding duodenal ulcer. Pathology on the FNA revealed SPT. The patient underwent a distal pancreatectomy and splenectomy with negative margins, and a normal spleen. Lymph nodes were negative for malignancy. The patient did well post operatively with resolution of his symptoms. DISCUSSION: SPT is a rare tumor predominately seen in females. In men it tends to occur at an older age with an aggressive behavior. The origin of SPT is not clear. 60% of SPT are found in the body and tail of the pancreas. SPT is primarily benign but about 15% exhibit malignant features such as metastasis or invasion of adjacent structures. The most common sites of metastasis are the liver and peritoneum. Typical presentation is a palpable abdominal mass with symptoms of abdominal pain, nausea, vomiting and early satiety. The histopathology of SPT reveals solid nests of poorly cohesive cells resulting in a pseudopapillary architecture with positive nuclear staining for beta catenin, positive immunostaining for CD10, CD56, vimentin; they are negative for chromogranin. Cystic fluid is often bloody with low CEA and low amylase. Surgical resection is curative. The five-year survival rate is 95%.

Kawasaki shock syndrome in an Arab female: case report of a rare manifestation and review of literature

BackgroundKawasaki disease shock syndrome is a relatively new and rare complication of Kawasaki disease first described in 2009.Case presentationThis report describes a two-year-old Arab descent female presenting with a history of high-grade fever of 2 days duration with non-specific signs of viral illness and erythematous rash. The patients’ condition deteriorated rapidly requiring admission to intensive care unit. In the intensive care unit, she developed a right upper quadrant mass that was diagnosed as hydrops of the gallbladder by ultrasonography. After one dose of intravenous immunoglobulin, the patient started to recover and was transferred out of intensive care after 2 days.ConclusionAmong the complications of Kawasaki disease, shock syndrome is rare and usually will have deleterious results if not diagnosed and managed promptly.

Large gastric trichobezoar causing failure to thrive and iron deficiency anaemia in an adolescent girl: a case report emphasising the imaging findings and review of the literature.

Failure to thrive, iron deficiency anaemia and abdominal pain are common paediatric presentations to general practitioners, outpatient clinics and are often referred to emergency departments. When young female patients suffering from psychiatric disorders, such as trichotillomania and trichophagia present to medical practitioners, the rare diagnosis of a trichobezoar, which is an accumulation of indigestible human hair in the gastrointestinal tract (90 % occurring in the stomach) needs to be suspected. Imaging is the mainstay of trichobezoar diagnosis and requires accurate interpretation to prevent complications. A case of a 14-year-old girl is presented, who was referred from paediatric outpatient clinics for an elective admission to the emergency department. She presented with abdominal pain, iron deficiency anaemia, failure to thrive and an epigastric/left upper quadrant mass felt on examination. A large trichobezoar was found on CT images, confirmed on endoscopy and removed with an open laparotomy. However, on the work-up imaging modalities, the radiologists missed the subtle findings of a trichobezoar. Although uncommon, trichobezoars should be considered as a differential diagnosis in female paediatric patients with a psychiatric history, who present with abdominal pain and epigastric mass. Imaging is the mainstay for trichobezoar diagnosis. As such, radiologists need to be familiar with the apparent, and subtler, pathological findings of this diagnosis and possible differential diagnoses across all imaging modalities. After successful treatment, psychiatric consultation and treatment is imperative in order to prevent reoccurrence.

Spigelian hernia in the right upper abdominal wall: a case report

BackgroundSpigelian hernia (SH) is rare and constitutes less than 2% of all hernias. It is reported that more than 90% of SHs lie in the “Spigelian belt”, but SH in the upper abdominal wall is extremely uncommon. Here, we report a case of SH in the right upper quadrant of abdomen.Case presentationA 38-year-old female was admitted to hospital with complaints of abdominal pain and right upper quadrant mass for 10 days. Contrast-enhanced computed tomography (CECT) of abdomen revealed the dilated small intestine between the swelling ventral muscles in the right upper abdominal wall which suggested a ventral hernia. The surgeons considered it was a spontaneous hernia because there was no history of surgery or trauma in the upper abdomen. About two hours later, the patient underwent emergency surgery. According to laparotomy, a diagnosis of SH with ileum herniation in the right upper abdominal wall was confirmed. The necrotic ileum segment was resected. Meanwhile the abdominal wall defect was repaired by suturing the internal oblique and transverse muscles to the rectus sheath. The patient had a favorable outcome for 1 year without recurrence.ConclusionA mass and pain in the upper abdominal wall may suggest an atypical SH. SH occurring in the upper abdominal wall is a rare condition with possibility of dire outcome if not managed early.

Peritoneal pseudotumoral actinomycosis: A case report

Abdominal actinomycosis is an uncommon abdominal disease caused by Actinomyces species. It may appear as an abdominal mass and it has a tendency to infiltrate adjacent tissues this is why it is often mistaken for a malignant tumor. We report a case of a man who consulted our institution for abdominal pain and a palpable right upper quadrant mass. Computerized tomography (CT) scan showed intra-peritoneal tissue mass with irregular contours that invades the left colon and infiltrates the abdominal oblique muscles. The biopsy under colonoscopy could not eliminate a malignant tumor. A scanner-guided biopsy confirmed the diagnosis of actinomycosis. The sample revealed the presence of voluminous clumps of rounded basophilic germs, filamentous in appearance. High dose IV penicillin therapy was given with complete resolution of symptoms and a complete disappearance of the colonic wall thickening as well as the invasion of the abdominal wall in the CT.

Malignant Tumors of the Spleen

Malignant tumors of the spleen are rare lesions that can be divided into three broad categories: lymphoproliferative diseases, metastatic lesions, and primary splenic (nonlymphoid) malignant neoplasms. Additionally, although myeloproliferative diseases are not tumors of the spleen, they do have the potential to either directly or indirectly affect splenic function, often manifesting as splenomegaly, hypersplenism, or both. Lymphoproliferative and myeloproliferative diseases are almost always systemic diseases. Consequently, medical therapy is the primary treatment, and splenectomy is currently reserved for patients with hematologic disorders refractory to medical management—for palliation of symptoms caused by splenomegaly or hypersplenism—and in the rare case of the pure splenic form of the disease. Patients affected by malignant splenic lesions often present with vague symptomatology, including generalized malaise, fatigue, weight loss, and fever. These symptoms may be accompanied by abdominal pain, a palpable left upper quadrant mass, or overt splenomegaly. Radiologic imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is mandatory in the evaluation of splenic tumors and may narrow the differential diagnosis. Management of splenic metastases should be individualized and, whenever possible, determined in a multidisciplinary setting. Splenectomy is the treatment of choice for patients with primary malignant tumors of the spleen in the absence of metastatic disease. This review contains 10 figures, 8 tables and 51 references Key words: angiosarcoma, leukemia, malignant splenic tumor, metastatic splenic tumor, spleen, splenectomy, splenic lymphoma

Malignant Tumors of the Spleen

Malignant tumors of the spleen are rare lesions that can be divided into three broad categories: lymphoproliferative diseases, metastatic lesions, and primary splenic (nonlymphoid) malignant neoplasms. Additionally, although myeloproliferative diseases are not tumors of the spleen, they do have the potential to either directly or indirectly affect splenic function, often manifesting as splenomegaly, hypersplenism, or both. Lymphoproliferative and myeloproliferative diseases are almost always systemic diseases. Consequently, medical therapy is the primary treatment, and splenectomy is currently reserved for patients with hematologic disorders refractory to medical management—for palliation of symptoms caused by splenomegaly or hypersplenism—and in the rare case of the pure splenic form of the disease. Patients affected by malignant splenic lesions often present with vague symptomatology, including generalized malaise, fatigue, weight loss, and fever. These symptoms may be accompanied by abdominal pain, a palpable left upper quadrant mass, or overt splenomegaly. Radiologic imaging, including ultrasonography, computed tomography, and magnetic resonance imaging, is mandatory in the evaluation of splenic tumors and may narrow the differential diagnosis. Management of splenic metastases should be individualized and, whenever possible, determined in a multidisciplinary setting. Splenectomy is the treatment of choice for patients with primary malignant tumors of the spleen in the absence of metastatic disease. This review contains 10 figures, 8 tables and 51 references Key words: angiosarcoma, leukemia, malignant splenic tumor, metastatic splenic tumor, spleen, splenectomy, splenic lymphoma

Delayed diagnosis of transanal prolapse of an ileo-colic intussusception in a 10-month-old infant in rural Cameroon: a case report

BackgroundTransanal protrusion of intussusception is a complication of intussusception which involves the exteriorization of the apex of the intussusceptum through the anus. However, it is rarely reported and its confusion with rectal prolapse often leads to a diagnostic delay.Case presentationA 10-month-old female with no significant past history from a rural area in the Extreme North region of Cameroon was referred from a local health centre to our emergency deparment for an irreducible mass. It was reported that the child had spent 5 days at home on over-the-counter medication, then 3 days at a health centre where she was being treated for a respiratory tract infection and a rectal prolapse. On arrival at our hospital, she was conscious and moderately dehydrated. Cardiopulmonary examination revealed generalized coarse crackles over both lung fields. Her abdomen was tender, with a left upper quadrant mass, absent bowel sounds and a dark anal mass. In view of these, diagnoses of bronchopneumonia, intestinal obstruction and a probable rectal prolapse were made. An exploratory laparotomy was carried out after resuscitation with per-operative findings of a prolapsed ileo- colic intussusception and a necrosed intussusceptum. The necrosed portion was resected and an end-to-end ileo-transverse anastomosis was carried out. The immediate post- operative period was uneventful, but the patient died 3 days after the surgery, from an overwhelming sepsis.ConclusionsTransanal protrusion of intussusception requires timely surgical intervention to prevent mortality. The similarity in presentation to rectal prolapse coupled with inadequate knowledge on the condition by primary healthcare personnel causes a delay in the diagnosis and an increased mortality. A high index of suspicion is essential for an early diagnosis and an improved referral system for timely and definitive treatment.

Squamous Cell Carcinoma of the Pancreas, a Treatment Dilemma: Case Report and Review of Literature

Primary squamous cell carcinoma (SCC) of the pancreas is rare and little is known about its risk factors, course, and response to chemotherapy. However, it has been shown to have worse survival rates than adenocarcinoma. The median survival of non-resectable SCC of the pancreas is 3 months. This is in part due to the absence of clear guidelines on its management, and oncologists often resort to case reports for management of the disease. A 59-year-old male patient presented with chronic abdominal pain, generalized back pain and fatigue. Imaging revealed a left upper quadrant mass arising from the pancreatic tail, with innumerable liver metastases. Pathologic exam of the liver lesions confirmed the diagnosis of metastatic poorly differentiated SCC of pancreatic origin. The incidence of Squamous cell cancer of the pancreas ranges between 0.05- 5%. As pancreatic SCC is a diagnosis of exclusion, other primary SCC sources must be ruled out. Differentiating features between adenocarcinoma and SCC include: enhancement of tumor on contrast CT + increased attenuation with contrast, and tumor blush pattern on angiography. EUS- guided biopsy has a sensitivity of 90% and specificity of 96%, and remains the diagnostic gold standard. In our patient, further workup did not detect any other primary sources. We concluded that this was a case of primary SCC of the pancreas. Pancreatic SCC poses a treatment challenge. There are no specific management algorithms demonstrating superiority of any specific chemotherapeutic regimen. Pancreatic adenocarcinoma therapy guidelines are usually followed for its treatment. Some physicians resort to case reports with experimental therapies, with some papers suggestig supperior results over the conventional Adenocarcinoma treatment. We believe it is important that further studies be conducted for pancreatic SCC specific therapies.FigureFigure: Liver core biopsy replaced by carcinoma producing nests with necrosis and focal keratinization.Figure. 6: 9 x 6.6 x 5.8 cm left upper quadrant enhancing lobular hypoattenuating mass appears to arise from the pancreatic tail with evidence of metastatic disease to the liver.

Gastrogastric Intussusception Caused by Gastric Mass

A 65-year-old woman with a past medical history of peptic ulcer disease and migraine headaches presented to our GI clinic complaining of dull left upper quadrant abdominal pain without radiation for the past 3 years. In addition she complained of unintentional weight loss and intermittent melena. She denied use of NSAIDs or a family history of gastric cancer. On exam, a palpable left upper quadrant mass was appreciated. A CT scan of the abdomen and pelvis with oral and intravenous contrast showed a gastrogastric intussusception without a clear lead point. Upper endoscopy revealed a 4.5 cm subepithelial mass with an overlying ulceration arising from the anterior wall of the body of the stomach. Mucosal biopsies of the mass were non-diagnostic however given the clinical presentation and concern for GIST, surgery was recommended. Patient underwent a laparoscopic partial gastrectomy with pathology showing GIST.Figure: (A) portable Chest x-ray (CXR) revealing left hemi-thorax findings were suspicious for left diaphragmatic hernia containing bowel loops. (B, C,D) Axial and Coronal contrast-enhanced CT scan of the Abdomen with 3D reconstruction showing left hemi-diaphragm defect with a large portion of the stomach herniating through it. (L:liver; St:stomach; K:kidney; Sp:spleen).Figure: EGD findings: (A) ulcerative esophagitis. (B and C) Endoscopic exam of the stomach fundus showed hyperemic gastric mucosa, with two outlet channels, one of which was blind and other one was going into the pylorus with significant looping through this area. (D) pylorus. (E) Pyloric sphincter (F) Duodenum.Most documented cases of intussusception occur in children (90%) rather than adults (10%). 95% of children have primary intussusception, whereby the etiology is benign and idiopathic without defined causes. In contrast, almost 90% of the cases of intussusception in adults are secondary to a pathologic condition that serves as a lead point, such as carcinomas, polyps, Meckel's diverticulum, colonic diverticulum, strictures or benign neoplasms. Secondary intussusception is believed to initiate from any pathologic lesion of the bowel wall or irritant within the lumen that alters normal peristaltic activity and serves as a lead point, which is able to initiate an invagination of one segment (intussusceptum) of the bowel into the other (intussuscipien). Classic triad of cramping abdominal pain, bloody diarrhea and a palpable mass is rare in adults. Symptoms could range from nausea, vomiting, and gastrointestinal bleeding to a change in bowel habits, constipation or abdominal distension. CT scan is the most sensitive radiologic modality to confirm intussusception with a characteristic “target” sign when the intussusception is perpendicular to the long axis or a “sausage” sign when it is parallel to the long axis. Intussusception in adult needs surgical resection or investigation given the high risks of secondary causes such as neoplasm.Figure: Sausage-shaped mass indicates gastrogastric intussusceptions.Figure. 4: 5 cm smooth with central ulceration mass arising from body of the stomach.Gastrogastric intussusception is rare. Fortunately for our patient the intussusception was transient allowing time for work up and elective surgery.

Pancreatic neuroendocrine tumor with metastasis to the spleen: a case report

BackgroundLong-term term survival in patients with pancreatic neuroendocrine tumors has been reported, even in patients with metastatic disease. Metastases to the spleen are extremely rare, but have been reported from a number of primary malignancies, such as breast cancer, lung cancer, melanoma and ovarian cancer. This is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor.Case presentationThe patient presented as a 53 years old white male with anemia and fatigue. Physical examination revealed a left upper quadrant fullness and computed tomography showed a 24 cm left upper quadrant mass with multiple liver metastases, splenomegaly and a 1 cm mass in the spleen. Resection of the primary pancreatic tumor (T4N0M1) was accompanied by gastrectomy, splenectomy and resection of adherent bowel. The spleen contained a metastatic lesion 1.0 cm in diameter, consistent with a primary neuroendocrine tumor of the pancreas. This operation was followed 8 months later, by delayed resection of liver metastases. The patient receives monthly administration of somatostatin long-acting analogue and has undergone several ablations of liver lesions with percutaneous radiofrequency ablation as well as a second liver resection. The patient is alive seven years after initial presentation, with no evidence of disease on imaging studies.ConclusionsThis is the first report of a splenic metastasis from a primary pancreatic neuroendocrine tumor. The patient initially presented with synchronous multiple liver metastases and a single splenic metastasis. After resection of the primary tumor and spleen, the patient has undergone aggressive cytoreductive surgery/ablation of liver lesions and somatostatin therapy with resulting long-term survival.

CHOEDOCHAL CYST: OUR EXPERIENCE IN A SINGLE CASE BY LAPAROSCOPIC APPROACH

<strong>Introduction</strong> Choledochal cysts are disproportionate dilatations of the biliary system for the presence of a congenital malformation, the persistence of the common biliary pancreatic channel. Complete excision of the cyst is the best treatment strategy to avoid long-term complications especially malignant transformation, recurrent cholangitis and gallstones. We present a clinical case treated at our center with minimally invasive surgery. <br /><strong>Case Report</strong> A female patient was admitted to our center at the age of 3 years, with right hypocondrial pain, followed by jaundice, vomiting and recurrent fever. No abdominal mass present. Abdominal ultrasound was performed and also Magnetic resonance cholangiopancreatography. According to the Todani classification modified by Alonso-Lej classification we identified a type I with three gallonstones. She underwent laparoscopic cyst excision and hepatico-jejunostomy Roux-en-Y with perianastomotic drainage positioned. No early and late postoperative complications after 1 year of follow-up. <br /><strong>Discussion and Conclusions</strong> Choledochal cysts can present at different ages with variable symptoms. Common presentations include abdominal pain, jaundice, and right upper quadrant mass and are most common seen in pediatric patients. Associated congenital anomalies of biliary tract may be present. Most cases of choledochal cyst disease have type I and IV-A cysts. If left untreated, choledochal cysts have an increased risk of malignant transformation. Early surgical excision and restoration of biliary tract continuity is mandatory, whatever the symptom severity to avoid long term complications whenever possible. Currently the gold standard treatment is the mini invasive surgery, in fact the advantages of this technique is the intraoperative visualization of deeper structures, decreased postoperative pain, shorter hospital stay, improved cosmetic result and decreased postoperative ileus. However, these cases remain reserved for highly specialized surgeons with a thorough understanding of hepatobiliary anatomy and minimally invasive techniques. Finally, limited case series of robotic pediatric choledochal cysts resection and reconstruction have been reported with acceptable outcomes, although more studies are needed before widespread acceptance and implementation of this technique in pediatric age.

Laparoscopic Marsupialization of a Giant Non-Parasitic Splenic Cyst (Npsc) in the Paediatric Age Group

AbstractNonparasitic splenic cysts are rare clinical lesions of the spleen. The management has entailed partial or total splenectomy via an open approach. Recently, laparoscopic approaches have been developed. In this report, we describe laparoscopic marsupialization of a giant splenic cyst (diameter > 15 cm).A 15-year-old Indian child presented with a four and a half year history of mass in upper left quadrant associated with left upper quadrant pain which increased since 2 days. Physical examination revealed a large, nontender left upper quadrant mass with minimal movement on respiration. Computed tomography scan confirmed a cyst arising from the spleen, measuring 20 x 15 cm suggestive of a primary splenic cyst. Echinococcus and Entamoeba histolytica serologies were negative. Laparoscopic exploration was performed. three liters of brown fluid were aspirated and intraoperative cytology confirmed a nonparasitic cyst. The cyst wall was excised, preserving the spleen. The patient's recovery was uneventful, and he was discharged, tolerating a regular diet on postoperative day 3. At follow-up, the patient was asymptomatic and showed no evidence of recurrence. Non-parasitic splenic cysts are rare lesions. Laparoscopic marsupialization is safe and effective and should be considered the treatment of choice even for giant splenic cyst.

Near Term Rudimentary Horn Pregnancy with Term Intrauterine Pregnancy: A Case Presentation

Introduction: Unicornuate uterus accounts for 5 percent of all Mullerian anomalies.Rarely it could be a site for ectopic pregnancy, where natural course is rupture during second trimester, with a potentially life-threatening heavy bleeding. However, in about 10 percent of cases horn pregnancy will go to term or form a lithopedion. We describe an unexpected horn pregnancy reaching near term with live term intrauterine pregnancy, an unusual presentation. Case presentation: 25 years old Gravida III, Para II woman presented to our hospital with complaint of right upper quadrant swelling of 5 months duration. Thirteen months back, she was diagnosed to have IUFD with femoral length of 34 weeks and misoprostol used for induction of labor but failed. Patient went home and she came again with the above complaint. On examination, uterus was 26 weeks sized, positive fetal heartbeat. She has 20 cm × 20 cm firm, non-tender right upper quadrant mass. Ultrasound showed singleton intrauterine alive pregnancy of 26 weeks + 5 days and dead fetus of 34 weeks by femur length in the right abdominal cavity. Transverse lower uterine segment cesarean was done to effect 3800 gm male alive neonate. Resection of rudimentary horn and right salpingectomy was done. The horn was connected to the isthmic right wall of the uterus by a thin fibromuscular tissue and contained 2200 gm macerated fetus and placenta. No right ovary seen. The patient and neonate progressed well and were discharged. Conclusion: An ectopic pregnancy in a rudimentary horn is rare and carries severe maternal and fetal consequences; antenatal diagnosis is challenging. Therefore, high index of suspicion is recommended to prevent morbidity and mortality after failed induction. The life-threatening complication is rupture of the horn.

Müllerian Remnant Cyst as a Cause of Acute Abdomen in a Female Patient with Müllerian Agenesis: Radiologic and Pathologic Findings.

We report a case of a 17-year-old female with Müllerian agenesis who presented with right sided abdominal pain clinically suspicious for acute appendicitis. Multimodality imaging workup revealed a heterogeneous cystic right upper quadrant mass with surrounding fluid and inflammatory changes. Surgical resection of this mass was performed and a histopathologic diagnosis of a hemorrhagic Müllerian remnant cyst was made, which to the best of our knowledge has never been described in a patient with Müllerian agenesis.

Surgical Treatment for Hypoglycemia: A Case Report

A 55 year old female presented large left upper quadrant mass and episodes of recurrent hypoglycemia. Preoperative laboratory testing revealed normal insulin, IGF-I and IGF-II levels. Big-IGF-II levels were unable to be measured because the laboratory test was unavailable. A CT scan of her abdomen and pelvis revealed a large 19 × 15 × 12 cm left upper quadrant mass appearing to involve the pancreas, spleen, and left kidney. The mass was surgically extirpated and was consistent with a hemangiopericytoma. Subsequently, her hypoglycemic attacks along with abdominal symptoms resolved. We hypothesize that this patient’s hypoglycemic attacks were a consequence of tumor secretion of a pro-hormone form of IGF-II called ‘Big IGF-II’.

Diagnostic Utility of Endoscopic Ultrasound Guided Fine Needle Aspiration for a Rare Presentation of Abdominal Burkittʼs Lymphoma

A 61 year old obese Caucasian male presented with constant epigastric pain, nausea, and vomiting for 5 days along with early satiety and significant weight loss over the past year. On examination a firm right upper quadrant mass was palpable and succusion splash was present. Initial blood chemistries were significant for elevated lipase, bilirubin, transaminases, and CA-19-9. MRI of the abdomen at an outside hospital showed a soft tissue mass measuring 11x12x13 cms involving the pancreatic head, and colon (transverse, ascending and hepatic flexure). CT angiogram of the abdomen revealed the presence of a large soft tissue mass 12x11x13 cms in the right upper quadrant which circumferentially surrounded the duodenum and was indistinguishable from the head of the pancreas and hepatic flexure of the colon. No retroperitoneal lymphadenopathy was identified. EGD showed extrinsic compression of the mid-to-distal stomach on the lesser curvature and gastric antrum. The endoscope was unable to reach the duodenum. EUS from the gastric body showed an irregular round heterogeneous mass in the RUQ perigastric peritoneal space. The pancreatic duct was dilated and measured 5 mm. FNA was performed with histomorphological and immunohistochemical staining features showing Burkitt-like subtype of B-cell lymphoma. The patient was started on chemotherapy with Hyper-CVAD regimen which resulted in symptomatic improvement of his gastric outlet obstruction within 5 days. A repeat CT scan after 2 months showed complete resolution of the abdominal mass. This case is a unique presentation of a solitary intra-abdominal mass of sporadic Burkitts lymphoma without lymphadenopathy in an adult. Despite the use of MRI and CT abdomen, it was not possible to determine the origin of the right upper quadrant mass causing gastric outlet obstruction in this patient. Inability to introduce the scope into the duodenum limited further characterization by ultrasound. Therefore obtaining a tissue sample was the only means of accurately knowing the origin of the mass, vital information to guide treatment options. This case illustrates the benefit of EUS with FNA in the prompt tissue diagnosis and treatment resulting in complete resolution of the mass. It further demonstrates that more invasive procedures such as CT guided biopsy and laparoscopy can be avoided in such patients.Figure 1Figure 2

Endometrial stromal sarcoma presenting as large bleeding left upper quadrant mass.

Endometrial stromal sarcoma (ESS) represents only 0.2% of all uterine malignancies. Even fewer cases have been reported on patients presenting with symptomatic disease. We report the case of young lady presenting with a large bleeding abdominal mass. At the time of surgery, an en bloc excision of the mass with a partial pancreatectomy, splenectomy, transverse colectomy, left nephrectomy, left adrenalectomy and resection of the diaphragm was performed. The final pathology revealed a malignant spindle and epithelial cell neoplasm with features favoring a variant of ESS. ESS can present in an atypical fashion as an intra-abdominal mass; a multi-disciplinary treatment approach for patients with this disease is crucial.