Bowel Obstruction as the Initial Presentation of Urothelial Carcinoma.

Bowel obstructions are one of the main causes of hospital admissions for acute abdominal pain. In addition, bladder cancer is one of the most common cancers in the world. This said, bowel obstruction and bladder cancer are very frequent diseases but the same cannot be said about the association between these two pathologies. We report a unique case of an 80-year-old patient admitted to the emergency room with a bowel obstruction caused by a urothelial carcinoma with adrenal metastasis. The patient underwent an urgent laparotomy, and intraoperative inspection of the peritoneal cavity confirmed a large tumorous mass suspected of gastrointestinal etiology. The mass infiltrated the ileum and sigmoid colon and was apparently in contact with the bladder wall. An en-bloc resection of the lesion was performed. An R0 excison was not possible and fragments of the lesion were excised from the bladder wall for separate analysis. Histopathological examination of the resected specimen described a high-grade, undifferentiated urothelial carcinoma that originated in the bladder and invaded the ileum and sigmoid colon. The presence of an invasive urothelial carcinoma presenting with bowel obstruction represents an unexpected diagnosis and, although rare, the surgeon must be aware of this possibility. This case should serve as a reminder that a broad differential diagnosis should be considered when investigating an abdominal tumor.

The Management and Challenges of Laparoscopic Cholecystectomy in Situs Inversus Abdominalis.

Left-sided gallbladders are rare anatomical variations and a result of an abnormal embryological process. The most frequent cause for a sinistroposition gallbladder is the presence of situs inversus. We present a case of a 51-year-old male referred to the General Surgery consult due to cholelithiasis with a history of occasional post-prandial abdominal pain in the left hypochondrium and nausea associated with the ingestion of lipid-rich meals. The ultrasound revealed a gallbladder filled with calculous but without inflammatory signs or bile duct dilation, in the sinistroposition. Magnetic resonance imaging (MRI) confirmed and excluded further anatomic variations. The patient underwent a laparoscopic cholecystectomy due to symptomatic cholelithiasis without any complications and was discharged the following day. When faced with a patient with gallbladder/biliary duct disorders associated with situs inversus, one must have a high clinical index of suspicion to properly diagnose and the mental agility to adapt and further operate in a mirrored-positioned abdomen. In these situations the patient should always undergo a prior MRI to determine the correct anatomy of the biliary system and the surgeon should perform an intraoperative cholangiography if any other variations are suspected. The presence of situs inversus thus imposes a surgical and diagnostic challenge. Although rare the surgeon must be aware of this possibility.