Vague Abdominal Symptoms Research Articles

Presentations of Waugh’s syndrome:intra-luminal cecal cyst and trans-anal prolapsing intussusception: a case report

BackgroundIntussusception with intestinal malrotation is termed as Waugh’s syndrome. The incidence of Waugh’s syndrome is less than 1%. There are very few reported cases. Once presented, it is a pediatric surgical emergency.Case presentationWe present here two cases of Waugh’s syndrome: an 11-month-old male patient of Punjabi descent and a 4-month-old female patient of Afghan descent who presented to us with abdominal pain and bleeding per rectum. Abdominal sonography revealed an intussusception with a target sign. They were explored and perioperatively had intestinal malrotation alongside intussusception, thus a diagnosis of Waugh’s syndrome was made. A right hemicolectomy and Ladd’s procedure was performed.ConclusionWaugh syndrome is a rare congenital anomaly but can present with vague abdominal symptoms. Once presented, it is a pediatric surgical emergency. The patient should be optimized followed by surgical exploration.

HPB P02 Leiomyosarcoma of IVC

Abstract Background Leiomyosarcoma of the inferior vena cava (IVC) is a very rare entity with poor 5-year prognosis. Less than 400 cases have been reported in literature. The extent of mass forming lesions is quite progressed upon discovery and multiorgan resection is often required. Here we present our 5year experience and surgical management of this malignancy. Methods From 2000 - 2023, 7 cases with IVC Leiomyosarcoma were treated in our institution. The median patient age was 59 years old with female gender predominance involvement. All patients presented with vague abdominal symptoms prompted imaging studies discovering the tumour, or the latter was an incidental finding of a retroperitoneal mass involving the IVC and adjacent organs (liver, kidney, duodenum). Only 4 patients (56%) had preoperative CT guided biopsy confirming the diagnosis and 3 cases were confirmed from post operative histology. Results All cases were reviewed in our multidisciplinary meeting and 4 patients (56 %) underwent surgical resection with caval replacement using a graft apart from one case which underwent IVC ligation. Liver resection was required after portal flow manipulation in two cases. Postoperative complications were ascites and chyle leak which were managed conservatively. Resection margins were negative (R0) to all cases. One case recurred and underwent further liver resections. Chemotherapy was offered only to unresectable cases (42%). From resected patients three of them (42%) are still alive with longest follow up of 4.5years post-resection and one died after multiple resections. Conclusions IVC Leiomyosarcoma is an aggressive malignancy and requires major surgery upon diagnosis. Surgery is the gold standard treatment since unrespectability upon diagnosis has poor prognosis. Due to rarity of the disease, large studies are difficult to be conducted.

117 Double Trouble: Rapunzel Syndrome Presenting with Closed-Loop Intestinal Obstruction Between Two Synchronous Trichobezoars

Abstract Background Trichobezoar formation is a rare phenomenon associated with certain psychiatric conditions like trichophagia and is more frequent in young women. Rapunzel Syndrome denotes a gastric trichobezoar which extends into the duodenum. We report a rare case of dual isolated trichobezoars, a gastric and an ileal trichobezoar, causing sub-acute closed-loop intestinal obstruction between the two bezoars. Case presentation A 15-years old girl presented to the emergency department with history of generalized abdominal pain and distention for two days. She had nausea, loss of appetite, absolute constipation followed by vomiting.She was tachycardiac, had abdominal distention with an ill-defined upper abdominal mass and absent bowel sounds. CT-scan abdomen revealed a giant trichobezor in stomach tailing into duodenum and a separate small rounded mass in ileum with dilated bowel loops. Mid-line laparotomy was done. Per-operatively a giant gastric trichobezoar(22x8cms) was extracted after gastrostomy, which completely occupied the stomach and extended into the duodenum. Another large ileal trichobezoar(6x5cms) was also removed via enterotomy at 2 feet proximal to the ileo-cecal junction. Hence a markedly distended closed loop was formed between the two obstructing trichobezoars. Enterotomies were closed using vicyrl2.0. Feeding was started on post-operative day-3 & she was discharged on day-5. She developed complete wound dehiscence after 2 weeks which was surgically closed. Patient was consulted for nutritional and psychiatric evaluation and for management of trichophagia. Conclusion Trichobezoars usually present with vague abdominal symptoms and can rarely cause intestinal obstruction. Invasive intervention such as laparoscopy or laparotomy becomes necessary for such large obstructing trichobezoars. Psychiatric follow-up and management are crucial to prevent its recurrence.

Combined hepatocellular and cholangiocarcinoma: A rare pathological diagnosis, clinically mimicking its parent phenotypes

A middle-aged female presented with vague abdominal symptoms that after diagnostic and staging work up was revealed to be an advanced case of combined hepatocellular and cholangiocarcinoma (cHCC-CCA). She was started on systemic chemotherapy inspite of which experienced disease progression

Fused Left Supernumerary Kidney with Single Blood Supply and Ureter

Abstract Supernumerary kidneys, also known as accessory kidneys, refer to the presence of more than two kidneys. It is a rare congenital abnormality of the urinary system with only a few cases reported so far in literature. The extra kidney commonly has its own collecting system, blood supply, and well-defined encapsulated tissue. It may or may not be fused to the other kidneys by fibrous tissue or a parenchymal bridge. Imaging for vague abdominal symptoms may result in an incidental finding of the rare anatomical variant which may indicate an adjustment of routine physical activities to avoid renal trauma, as well as relevant considerations for surgical planning. We present a 62-year-old woman who presented with vague abdominal pains. Findings on physical examination were unremarkable. Her abdominal ultrasound scan showed two kidneys of about the same size fused together. Computed tomography urography showed two fused renal tissues of nearly same size on the left. The accessory kidney is more medial, slightly cranial. The native kidney is more lateral and more caudal. The native and accessory kidneys had only one blood supply, venous drainage, and a single ureter. As at the time of reporting, the patient has not received any intervention because there was no remarkable symptom noted. This case is rare and unique, in that it is a fused supernumerary kidney seen at the age of 62 and has a single blood supply and ureter. Imaging for vague symptoms can result in an incidental finding of a rare anatomical variant. It is also very essential for planning surgical intervention if need be.

Race Against the Clock: An Atypical Cause of Abdominal Pain

ABSTRACT Aortoenteric fistula is a rare medical emergency that carries a high risk of mortality. In cases that present without gastrointestinal bleeding, it can be difficult to accurately diagnose and, therefore, properly manage. This case depicts a patient who presented with diffuse abdominal pain and obstipation. After imaging, esophagogastroduodenoscopy, and surgery, he was found to have an aortoduodenal fistula with an infected graft. Our case highlights the importance of maintaining a high index of suspicion for an aortoenteric fistula in a patient with vague abdominal symptoms and a significant history of vascular grafts.

A very challenging scenario of 52 ingested toy magnets causing multiple entero-enteric fistulas in a 5 year-old child

Foreign body ingestion is commonly seen in paediatrics. Magnets, button batteries and sharp objects can cause life threatening complications. Intestinal obstruction, peritonitis and fistula formation between bowel loops are reported complications to multiple magnets ingestion. We report a case of a 5-year-old who swallowed 52 toy magnets. He presented with peritonitic abdomen which required abdominal exploration, resection of necrotic bowel segments and 6 bowel anastomosis. The postoperative course was uneventful. The earliest report of multiple magnets ingestion was reported from Japan in 1995, which was complicated by bowel perforation.If the magnetic foreign bodies remain in a fixed position on repeated abdominal x-rays, surgical treatment should be considered even if the patient is asymptomatic, because, in such patients, entero-enteric intestinal fistulas are likely to have formed. The ingestion of multiple magnets can lead to life-threatening complications in children. One must have a low threshold for performing diagnostic imaging in children presenting with vague abdominal symptoms if there is a history of potentially ingesting a foreign body, even if unwitnessed.

Ultrasound Shear Wave Elastography of Normal Pancreas in Adult Subjects

Abstract Background and Purpose Transabdominal ultrasound (US)-based shear wave elastography (SWE) provides an attractive method of estimating pancreatic stiffness. There is limited data on the SWE values of the healthy pancreas in Indian subjects. The current study aimed to evaluate SWE of the normal pancreas. Methods We performed a study from January 2019 to March 2019. We included adult patients who presented for the US of the upper abdomen for vague abdominal symptoms, unrelated to the pancreas. The SWE values were obtained from the pancreatic head and body. The association of pancreatic SWE with age, gender, fatty liver, chronic liver disease, and cholelithiasis was recorded. Results During the study period, 205 subjects underwent SWE of the pancreas. The mean age of subjects was 41.3 (standard deviation [SD] 15.3) years. There were 93 males and 112 females. The mean SWE value in the head of the pancreas was 8.98 (SD 2.46 kPa), and that in the body region was 8.67 (SD 2.67 kPa). There was a positive correlation of SWE with age. The SWE of the pancreatic body was significantly higher in patients who had a fatty liver on US (p < 0.05). There was no significant association of SWE of the pancreas with gender, presence of chronic liver disease, or gallstones. Conclusion The normal values of pancreatic SWE are correlated with age and fatty change in the liver.

Foreign body ingestion: Is intervention always a necessity?

Intentional and accidental foreign body ingestion are commonly encountered in clinical practice. In adults, intentional foreign body ingestion is frequently observed among individuals with psychiatric disorders and prisoners. Controversies exist regarding the management of sharp or pointed objects. We contribute to this existing controversy by presenting a case of a 43-year-old male who accidently ingested a metallic screw and was managed successfully through endoscopic retrieval. We discuss a case of a 43-year-old male presented to our emergency department after accidently swallowing a metallic screw, 1h and a half prior to his presentation. He was initially asymptomatic then started to complain of vague abdominal symptoms. X-rays of the chest and abdomen demonstrated the presence of a metallic screw at the mid-abdomen. Computed tomography scan of the abdomen then confirmed its presence within the gastric lumen, with no evidence of gastric or bowel perforation. The patient was managed via esophagogastroduodenoscopy in which the ingested screw was extracted. He was discharged after 24 hours in a good condition. A limited number of epidemiological studies have shed light on the prevalence and incidence of foreign body ingestion among adult individuals. Probability of spontaneous passage depends on several factors including the size, shape and composition of the impacted item, as well as the age of patient and duration of ingestion prior to presentation. Considering the variation of ingested objects and the availability of several therapeutic approaches, a patient-tailored management plan should always be established.

S1766 Metastatic Renal Cell Cancer with Pancreatic Mass

Introduction: Pancreas is an uncommon site of metastatic disease. Almost 63% of pancreatic metastasis arise from renal cell cancer. We report a case of metastatic renal cell cancer to pancreas, with contralateral adrenal metastasis 15 years after a radical nephrectomy. Case Description/Methods: 61 years old man with past medical history of renal cell cancer, status post left radical nephrectomy fifteen years ago, presented with dull pain in right lower abdominal for one day. He denied any other abdominal symptoms or weight loss. He smokes up to half a pack of cigarettes daily. His examination was unremarkable but he was noted to have elevated lipase (213U/L) and a bilirubin of 1.1 mg%. On computer tomography abdomen he had bulky, enhancing, soft tissue mass (∼6.7 cm), with dilated pancreatic duct of 1.5 cm with right adrenal mass (Figure). On EUS, the lesion appeared well circumscribed and previously known pancreatic duct dilation was seen. Fine needle biopsy of the mass, which showed numerous atypical cells with round irregular nuclei with prominent nucleoli with clear cytoplasm suggestive of clear cell renal cell carcinoma (Figure). On immune -histochemistry, the tumor was positive for CD10, renal cell carcinoma antigen and PAX 8( Figure) Discussion: Metachronous renal cell cancer to pancreas fifteen years after radial nephrectomy is rare. Our patient had pancreatic metastasis with adrenal involvement and presented with vague abdominal symptoms. .He was noted to have elevated lipase and dilation of main pancreatic duct. Due to a remote history of nephrectomy and the presenting complaints, pancreatic primary was suspected. However, on endoscopic ultrasound the patient was noted to have a well circumscribed lesion in the head of pancreas with dilated pancreatic duct(Figure). Regular borders and absence of pancreatic duct dilation suggested metastatic disease. Our patient had well circumscribed lesion but with a dilated duct. Most pancreatic metastasis are reported to occur within 10 years after treatment of the primary disease but our patient had metastasis fifteen years later without any loco-regional recurrence. Endoscopic ultrasound is extremely important and allows to evaluate the extent of the disease, involvement of portal vein/ superior mesenteric artery, presence of enlarged lymph nodes, which are a must for evaluating the surgical candidature besides providing tissue diagnosis which helped us establish the diagnosis of metastasis.Figure 1.: CT(A,B,C) and EUS(D,E) findings. Image A shows the mass in the Pancreatic head(arrow with red head) with a dilated pancreatic duct seen in imageB( arrow with red head). Adrenal metastasis is seen in image C marked with a red arrow. On EUS, the mass appears well circumscribed( blue arrow, image D) with dilated pancreatic duct seen ( green arrow) in the head of pancreas in E.

S2071 Natural Killer Polyp

Introduction: Natural killer (NK) cells are cytotoxic lymphocytes that can induce an innate immune response against tumors and virally-infected cells. NK cell enteropathy (NKCE) is clinically indolent although histologically it resembles NK/T-cell lymphomas.1 Therefore, accurate diagnosis is instrumental to avoid overtreatment.1 Case Description/Methods: A 45-year-old female presented with 2 episodes of nocturnal left lower quadrant “labor-like” pain lasting for 1-2 hours each, which were not alleviated by ibuprofen or acetaminophen. She described her subsequent bowel movements as bloody, skinny stool. Her pain was associated with abdominal tenderness for 3 days. She denied a change in weight or appetite but did endorse decreased energy over the last several months. Her family history is limited since she was adopted. Physical examination and lab tests were unremarkable. Colonoscopy showed a flat, 1-cm polyp with 3 erosions in the rectum. Excisional biopsy revealed polypoid fragments of rectal mucosa with atypical lymphoid infiltrate with NK cell phenotype involving predominantly the mucosa and multifocally through the muscularis mucosa (Figure 1A and 1B). Immunohistochemical staining was positive for CD3, CD7, CD56, and BCL2. Ki-67 highlighted approximately 90% of the lesional cells. These results were consistent with NKCE. The CT was unremarkable. It was decided to manage her conservatively. Repeat colonoscopy 6-months later revealed a post-polypectomy scar in the rectum (Figure 1C). Scar biopsy was negative for abnormal cells. She followed up with oncology and has been in remission for more than 5 years. Her most recent colonoscopy still showed an unchanged rectal scar. Discussion: The lack of systemic symptoms, the isolated colon location, and its EBV-negative staining point toward a diagnosis of NKCE rather than lymphoma. NKCE typically presents with vague abdominal symptoms and bleeding.1 Since NKCE mimics NK/T-cell lymphoma, it is important to accurately diagnose the disease to prevent erroneous overly aggressive treatment. Since this disease and the exact stimulus are not well established,1 further research needs to explore the appropriate standard of care for patients with NKCE.Figure 1.: A and B, histologic findings consistent with a diagnosis of natural killer cell enteropathy. C, post-polypectomy scar.

Superior mesenteric venous thrombosis presenting with hematemesis: a case report

The superior mesenteric vein (SMV) is one of the two tributaries to the portal vein, which is the main pre- hepatic drainage channel of the splanchnic circulation. Venous thrombosis in the SMV is one of the rare causes of splanchnic ischemic syndrome. Clinical presentation is often vague abdominal symptoms. It seldom presents with hematemesis, which may further confound diagnosis, thereby increasing the risk of poor outcomes. This case highlights an otherwise healthy 31-year-old woman, who presenting at a tertiary hospital in Nairobi with a 2-day history of epigastric pain and copious hematemesis. She had been treated for Helicobacter pylori gastritis 2 months prior. Common differentials were considered. However, with normal esophagogastroduodenoscopy findings and dark- colored fluid sequestered in the upper gastrointestinal tract, mesenteric venous congestion with associated small bowel ischemia was suspected. Three-phase abdominal computed tomography angiogram confirmed proximal superior mesenteric venous thrombosis extending into the portal vein confluence. Associated small bowel necrosis was suspected, and surgery involving resection and primary ileo-jejunal anastomosis was performed. Post-operative 2-week parenteral nutrition and anticoagulation were administered. The patient was discharged after 3 weeks of hospitalization and remains in excellent condition.

Large bowel obstruction secondary to a cecal bascule with internal herniation through the foramen of Winslow: A case report.

IntroductionInternal hernias are a rare phenomenon, and even rarer is a herniation through the foramen of Winslow. The clinical presentation of patients with an internal hernia is often vague and difficult to diagnose clinically. If internal hernias go undiagnosed and untreated, patients can develop bowel compromise leading to a high morbidity and potential mortality. Radiologic imaging is helpful in bringing the diagnosis to the forefront of the clinicians mind, but the diagnosis is often made intra-operatively.Presentation of caseAn eighty-one year old female presenting with a few months of vague abdominal symptoms who was found to have a cecal bascule internally herniating through the foramen of Winslow was treated successfully with surgical intervention.DiscussionInternal hernias occur when there is a protrusion of a viscera through the peritoneum or mesentery and confined within the abdominal cavity. Internal hernias are classified according to location and vary from paraduodenal, transmesenteric, and pelvic to name a few. Hernias through the foramen of Winslow are a rare subset, and were the internal hernia found in our patient intra-operatively. Our patient's clinical presentation was vague with generic abdominal complaints and radiologic imaging was inconclusive for a definitive diagnosis. However, prompt surgical intervention resulted in a good outcome for our patient.ConclusionInternal hernias, to be diagnosed and treated promptly, require a high index of suspicion from a clinician based on clinical presentation and radiologic imaging. These patients belong in the operating room, and interventions are directed based on the anatomical findings intra-operatively.

Case report of congenital intestinal malrotation in an adult discovered three months status-post appendectomy.

Introduction and importanceIntestinal malrotation is a congenital anomaly primarily diagnosed in children, with limited cases reported in adults. Prompt recognition is necessary to prevent life-threatening complications including bowel ischemia and death. We present a rare case of adult intestinal malrotation highlighting difficulty in diagnosis and surgical management.Case presentationA 37-year-old Caucasian woman presented with a 3-day history of worsening diffuse abdominal pain, three months status-post laparoscopic appendectomy. CT scan with contrast of the abdomen and pelvis demonstrated small bowel mesenteric swirling and descending duodenal transition point. Differential diagnosis included intestinal malrotation versus small bowel obstruction. Pre-operatively, the patient expressed frustration with years of abdominal pain and lack of improvement. Treatment with open surgical small bowel detorsion and ligation of the Ladd's bands was performed, after initial laparoscopic intervention was complicated by enterotomy. The patient recovered well post-operatively with final diagnosis of intestinal malrotation with midgut volvulus. Discharge home was delayed due to polysubstance withdrawal. Post-operatively, the patient reported immediate relief of symptoms which persisted at 2-week and 2-month follow-ups.Clinical discussionFew reports of congenital malrotation diagnosed in adulthood are reported. This highlights the importance of evaluating all patients for malrotation when the appendix is found outside of the normal positioning in the RLQ, as surgical correction of malrotation is of utmost importance in such patients.ConclusionClinicians should consider intestinal malrotation in adults with recurrent vague abdominal symptoms. To our knowledge, this is the first report of congenital malrotation discovered in an adult after prior appendectomy.

Clinical spectrum of Celiac Disease in adults at a tertiary care hospital in Karachi, Pakistan.

Objectives:Celiac Disease (CD) is a disorder that impacts physical, social and emotional health. Requiring life-long treatment, it poses a major economic burden on the healthcare system. Our objective was to study CD in patients from initial presentation to diagnosis and to ascertain the effect of a low resource setting on improvement in disease process.Methods:This is a retrospective cross-sectional study conducted at a Aga Khan University Hospital (AKUH), a tertiary care center in Karachi, Pakistan. Medical records of patients (≥ 18 years) from 2008 to 2018 with a diagnosis of CD were reviewed. Data on demographics, presenting complaints, investigations, endoscopy results and follow up visits was collected.Results:One hundred and twenty-six patients were included (61.6% females, mean age 35.5 years). The most common intestinal and extra-intestinal symptoms were abdominal pain (56.3%) and fatigue (24.6%) respectively. After microcytic anemia (36.5%), increased ALT (27.2%) was the most common laboratory derangement. On endoscopy, visible fissuring (29.4%) and atrophic mucosa (29.4%) were reported. Biopsy findings showed increased intraepithelial lymphocytes (92.9%) and villous atrophy (77.8%). Improvement in at least one of three parameters (symptoms, laboratory values or EGD) was reported by 42.0% of subjects, whereas 48.4% subjects were lost to follow-up.Conclusion:The most commonly reported symptoms by CD patients were abdominal pain, diarrhea and anemia. Thus, patients presenting with vague abdominal symptoms and anemia should be worked up for CD. A concerning majority of subjects was lost to follow up for reasons such as inability to afford advised GFD and a poor understanding of the disease process.

P-BN05 Solitary jejunal diverticulum: a rare unexpected cause of chronic pneumoperitoneum

Abstract Background Jejunal diverticula are rare acquired herniation of the mucosa and submucosa through the muscularis propria. They are asymptomatic in the majority of cases, however, they can present with non-specific abdominal symptoms and rarely complicate leading to acute abdomen. Perforation usually results in symptoms and signs of acute peritonitis and it is not an identifiable aetiology of chronic pneumoperitoneum. Computed tomography scan may identify intestinal wall oedema, air bubbles travelling through the mesentery, free intra-abdominal air and/or fluid . Radiological diagnosis requires high index of suspicion of such pathology. We report a case of an isolated jejunal diverticulum as a cause for aseptic chronic pneumoperitoneum . Methods A 77-year-old female was referred to the ambulatory emergency surgical unit (AESU) with a 4-month history of nonspecific abdominal pain, considerable weight loss, diarrhea, nausea and a few episodes of vomiting.Physical examination revealed no constitutional signs of sepsis and her abdomen was mildly distended but soft and nontender to palpation. Laboratory investigations were unremarkable. CT scan of her abdomen and pelvis on her first visit showed pneumoperitoneum with associated low volume ascites, which raised the possibility of sealed gastrointestinal perforation. In the absence of any clear signs of sepsis, a strategy of ambulatory, conservative management and follow up was chosen. Four months after her initial presentation our patient presented with ongoing vague abdominal symptoms with weight loss and failure to thrive. A CT colonogram described pneumoperitoneum and larger volume of ascites is in comparison to the previous CT scan. There was an unusual pattern of mural gas in some loops of small bowel in the left side of the abdomen that suggested pneumatosis. MDT decided to proceed with diagnostic laparoscopy. Results Laparoscopy exploration revealed odorless pneumoperitoneum, moderate amount of non-turbid bile stained serous ascites and thin fibrinous covering. We identified a jejunal diverticulum associated with mesenteric air bubbles and moderately enlarged reactive feeling lymph nodes in the diverticular segment . A small bowel resection with a primary side-to-side anastomosis, washout of the abdomen and cholecystectomy were done through a Kocher’s subcostal incision. She made an uneventful post-operative recovery and was discharged home well on day 4. Histopathological examination of the resected specimens confirmed the presence of a ruptured isolated jejunal diverticulum with a breach in muscularis propria and chronic cholecystitis in the gallbladder. Conclusions In summary, our case report highlights the importance of being aware of the possibility of perforated jejunal diverticula as a possible source of chronic pneumoperitoneum causing chronic nonspecific abdominal pain, diarrhea and unexplained weight loss. The surgical option of segmental resection and primary anastomosis was beneficial in this patient. However, calculating the risk benefit ratio remains the mainstay of the management plan, which, as ever, should be tailored to each patient’s general condition and fitness with appropriate counselling and consent.

Minimally invasive management of massive giant hydronephrosis in tertiary care centre Northern Sri Lanka: A case report.

Introduction & importanceGiant hydronephrosis (GH) is defined as a kidney containing greater than 1000 ml of urine in its collecting system. It is a rarely presented condition in an adult. Common aetiology for GH is due to congenital ureteropelvic junction obstruction. We present a case of a late presentation of GH was being managed by a minimally invasive laparoscopic technique.Case presentationA 63-year-old Sri Lankan male presented with worsening of generalized abdominal swelling with vague abdominal symptoms for a six-month duration, found to have a GH of the left kidney on USS. The Contrast-enhanced computerized tomography (CECT) scan confirmed the diagnosis with 12l of fluid and possible ureteropelvic junction obstruction (UPJO). CT did not show any excretion of the left kidney. Hydronephrosis was drained one day before the surgery by a percutaneous nephrostomy tube. Laparoscopic transperitoneal nephrectomy was performed. The patient had a smooth and fast recovery.DiscussionA neglected congenital UPJO can present with GH in adults. It causes vague abdominal symptoms like abdominal distension, dyspepsia, and fatigue. CECT will give the diagnosis and identify the aetiology of GH. Non-functional GH kidneys can be treated with nephrectomy by open or laparoscopic surgical technique. Laparoscopic nephrectomy shoes less blood loss during surgery, less postoperative pain and early recovery after surgery. However, in GH, surgeons need the experience to overcome the challenges like adhesions and working in a small space.ConclusionsThe percutaneous nephrostomy decompression followed by laparoscopic transperitoneal nephrectomy is feasible for a massive GH.

Role of Laparoscopy in the Diagnosis of Abdominal Tuberculosis in Patients with Vague Abdominal Symptoms

Background and Aim: Tuberculosis continues to be a common disease in Iraq and one of its presentations is abdominal tuberculosis which tends to present with non-specific features that can be hard to diagnose at times. Histopathological confirmation of abdominal tuberculosis is difficult because of suboptional, noninvasive access to the pathology. The aim of this study was to find out the efficacy of diagnostic laparoscopy in establishing the histopathological diagnosis of abdominal tuberculosis. Patients and Methods: A retrospective study conducted on 67patients with vague abdominal pain, with or without ascites, for whom diagnostic laproscopy was performed in Azadi Teaching Hospital in Kirkuk City over a period of six years (January 2007 - December 2012). Data were collected and statistically analyzed using SPSS software version 16. Results: A total of (67) patients with vague abdominal symptoms and an unsettled diagnosis were included in this study, of which 22(32.8%) of the patients were diagnosed with abdominal tuberculosis on laparoscopy. The common symptoms were abdominal pain, changing bowel habits, loss of weight, fever and generalized weakness. The most consistent laboratory finding (>86%) was a high ESR. Macroscopic findings of abdominal tuberculosis were whitish granulations over both peritoneal layers, inflammatory adhesions on the visceral or parietal surface, thickening, hyperemia and retraction of the greater omentum and stalactic band which is characteristic of abdominal tuberculosis. Direct visualization of the peritoneum and obtaining peritoneal biopsies provided the definitive tissue diagnosis to confirm the clinical diagnosis. Conclusion: Although other diagnostic methods of abdominal tuberculosis such as imaging, culture of ascites and polymerase chain reaction (PCR) are used today, laparoscopy with tissue biopsy provided efficient and reliable diagnostic tool for patients suspected with abdominal tuberculosis. Patients were saved from unnecessary laparotomies and were managed on anti-tuberculosis drug therapy.

Treatment of duodenal lipoma with robotic-assisted transverse duodenotomy: A case report of novel approach.

Introduction and importanceLipomas are the third most common benign tumor of the gastrointestinal (GI) tract, typically occurring in the colon or small intestine. Less than 100 cases of symptomatic duodenal lipomas have been reported. Symptoms include non-specific upper GI complaints of heartburn, fullness, or abdominal pain. This report highlights the rarity of symptomatic duodenal lipomas, lack of specific treatment guidelines, and adds to surgical literature a new treatment approach.Case presentationA 53-year-old Caucasian woman presented with 2-year history with main concerns for early satiety and constipation. CT scan with contrast of the abdomen and pelvis demonstrated a duodenal mass. Differential diagnosis included duodenal lipoma versus stricture, and IBS. Subsequent EGD revealed a 4 cm transverse duodenal submucosal mass. Endoscopic removal was deemed too great a risk of bleeding. Pre-operatively, the patient expressed frustration as the patient was tolerating only a liquid diet with one bowel movement weekly. Treatment with robotic assisted transverse duodenotomy was performed, with final pathology of benign lipomatous tissue. Post-operatively the patient had immediate relief of symptoms which persisted at 2-week and 4-month follow-ups.Clinical discussionThis case demonstrates 3 primary learning points. First, duodenal lipomas should be included in the differential of vague upper GI symptoms. Second, we propose that surgeons consider treatment of duodenal lipomas utilizing robotic assisted approach. Third, we document the first robotic-assisted transverse duodenotomy for duodenal lipomas.ConclusionClinicians should consider duodenal lipoma for patients with vague abdominal symptoms. We present a case of successful treatment with robotic-assisted transverse duodenotomy.

Mesothelial Cyst in a Young Female: Case report and literature review

Mesenteric cysts are rare intra-abdominal benign tumors (1 in 100,000 cases in adults) with various clinical presentations. [1,2] They commonly originate from the small bowel mesentery, although a proportion has been found to originate from the mesocolon, and retroperitoneum. [1,3] The formation of mesenteric cysts depends on the histologic origin, where they could be classified into cysts of lymphatic origin, cysts of mesothelial origin, cysts of enteric origin, cysts of urogenital origin, dermoid cysts and pseudocysts. [4,5] Diagnosis is extremely difficult since. The Mesenteric cyst is usually asymptomatic, but if symptomatic, abdominal pain (82%), nausea and vomiting (45%), constipation (27%) are the most common presenting symptoms. [2,3] The clinical finding of abdominal mass is encountered in more than 61% of the patients. [2,3]. As this condition is very rare and its symptomatology can resemble any other abdominal diseases, diagnosis is extremely difficult and incorrect preoperative diagnosis is often made. Hence, performing physical examination and conducting radiological investigations such as ultrasonography (USG) and computed tomography (CT) are important in making a correct diagnosis. [2,3] As well as cases of mesothelial cysts, they are typically asymptomatic but occasionally, their symptoms are vague and non-specific. [6,7] As mentioned above, imaging modalities such as USG, CT and magnetic resonance imaging (MRI) are great in identifying the character, size, location, surrounding tissues and the wall and content of the cysts. [7] Surgery is the treatment of choice, as a complete resection with negative borders is curative and often prevents recurrence. [3] We report a case of a young female patient who presented with a vague abdominal symptoms and a large cystic mass in lower abdomen. After proper evaluation, surgical exploration revealed a large simple mesothelial cyst.