Splenic artery pseudoaneurysm presenting with massive rectal bleeding.

Splenic artery pseudoaneursym is relatively rare and its rupture is usually fatal. We report a case of a 48-year-old male with 2 prior episodes of alcoholic pancreatitis that presented with massive per rectal bleeding from rupture of a splenic artery pseudoaneurysm into the transverse colon. Gold standard of diagnosis is CT angiography of the abdomen. We present the first case in the literature where a diagnosis has been made with noncontrast CT of the abdomen and described the radiologic features that facilitated this diagnosis.

Gallstone ileus 1 year after cholecystectomy.

Post-cholecystectomy gallstone ileus (GSI) is very rare with only 16 cases reported in the literature. This condition poses diagnostic challenges both because of its rarity and since the gallbladder had been previously removed. A high index of suspicion is needed for diagnosis. We report a case of a 37-year-old female who presented with GSI 12 months post-cholecystectomy.

CT guided appendicectomy incision: A prospective case series.

OBJECTIVE: Several radiological studies have suggested that the base of the Appendix often does not correspond with Mc Burney's point. The aim of our study is to assess the value of using CT localization of the appendicocaecal junction to guide placement of the appendicectomy incision. DESIGN & METHOD: 32 consecutive patients, booked for open appendicectomy were prospectively included in this study. Coronal and axial CT scans with IV contrast were studied to assess site of the appendicocaecal junction. This information was used to guide placement of the incision. RESULTS: 28 out of 32 patients studied, the appendicocaecal junctions were accurately identified. It was noted that the final incision sites were cephalad to Mc Burney's point in 8, at the point in 3 and caudal in 17. In 1 patient, it was necessary to extend the incision medially by 2cm to retrieve the distal Appendix which had been detached through the site of rupture. CONCLUSION: Mc Burney's point often does not correspond to the base of the appendix. We propose that using CT imaging to guide the appendicectomy incision is safe, facilitates locating the Appendix at surgery, minimizes incision size and decreases the need to extend it.

Multi-organ benign and malignant tumors: recognizing Cowden syndrome: a case report and review of the literature.

BACKGROUND: Cowden syndrome is an autosomal dominant disorder with a predisposition to multiple benign and malignant tumors. In our patient, in addition to breast and endometrial malignancies as well as facial trichilemmomas, she was noted to have multiple meningiomas, pancreatic lipomas and lung cysts. These latter lesions have been noted in previous Cowden syndrome case reports, but are not included in the diagnostic criteria at this time. To our knowledge, this is the first case of multiple meningiomas in this syndrome. Further studies are therefore warranted to assess the significance of these findings in Cowden syndrome. CASE PRESENTATION: A middle-aged Afro-Caribbean known endometrial carcinoma patient (post surgery and adjuvant radiotherapy), presented with a locally advanced breast carcinoma. She received neoadjuvant chemotherapy followed by a modified radical mastectomy and axillary lymph node clearance. Her past medical history included a sphenoid wing meningioma for which she received definitive external beam radiotherapy. She was also known to have a multinodular goiter, anal polyp and longstanding mucocutaneous lesions. Further workup revealed additional smaller meningiomas, a parotid arteriovenous malformation, a lung cyst and pancreatic lipomas. Overall, consortium criteria were met for the diagnosis of Cowden syndrome. Furthermore, genetic testing identified a pathogenic mutation in the PTEN gene. She will be closely followed with annual clinical examination, dermatologic assessment and screening colonoscopies. She will perform interval whole body contrast enhanced CT for continued surveillance for metastatic disease. CONCLUSION: Cowden syndrome is likely to be an under diagnosed condition, but critically important to identify due to its cancer predisposition. When encountering multi-organ tumors, diagnostic criteria for Cowden syndrome should be sought in order to increase the diagnostic rates. Cancer surveillance for carcinoma detection in the early and curative stages remains the most critical aspect of management.