Phyllodes tumour initially diagnosed as keloid.

It is unusual to find a breast tumour in a keloid, as the management of both is distinct. In this case, a young woman was operated on 4 years ago, for a right chest wall swelling, situated near the inframammary fold. The histopathological report revealed a granuloma, for which anti-tuberculosis treatment was given. However, the swelling recurred and progressed in size over the next 3 years. Then, she consulted the dermatology department, where the swelling was managed as a keloid. There was no remission. Consequently, the possibility of a breast tumour was suspected, and the patient was referred to breast services (subdivision of the surgery department).Triple assessment of the breast lump was suggestive of a phyllodes tumour (PT). Surgical excision of the tumour was done, which showed a malignant PT. Radiotherapy was given and delayed breast reconstruction was planned.

Metastatic anorectal malignant melanoma causing ileocaecal junction obstruction due to contiguous spread.

Malignant melanoma of the anal canal is a rare and aggressive tumour associated with significant mortality. Early diagnosis and early curative surgical resection have shown to offer a survival advantage. We present a case of 53-year-old woman, who was accidentally diagnosed to have a localised lesion of malignant melanoma of the anal canal on histopathology report of the specimen of haemorrhoidectomy done for thrombosed external haemorrhoids. She refused any form of treatment and did not return for follow-up. Two years after the initial diagnosis, she presented with intestinal obstruction. The malignant melanoma had become advanced with multiple metastases to the lungs, the liver, the peritoneum and the spine. The patient underwent a diverting loop ileostomy. At the time of surgery, it was found that the primary malignant melanoma of anal canal had contiguously involved the entire large intestine up to the ileocaecal junction and hence transverse colostomy could not be done.

Challenges in management of an isolated intrapancreatic Common Bile Duct injury in an abdominal trauma.

INTRODUCTION: Biliary tract injuries are rare following abdominal trauma. If detected late, outcome is less favourable. It adds to morbidity if there is involvement of head of pancreas or duodenal wall. CASE REPORT: We present a case of an adult male with sharp and blunt trauma over the right side of the abdomen with omentum protruding out. Exploratory laparotomy revealed non expanding paraduodenal hematoma without evidence of solid or hollow viscous injury. Post-operative day 2 drain showed bilious content. Contrast Enhanced CT scan ruled out the solid or hollow viscous injury. Magnetic Resonance choledocopancreaticography (MRCP) done on day 4 was suggestive of isolated intrapancreatic common bile duct injury of American Association of Surgery for Trauma (AAST) grade V. Endoscopic Retrograde choledocopancreaticography (ERCP) with stenting was done. Stent removal was done after 12 weeks. The patient is asymptomatic at 1 year follow up. DISCUSSION: Due to limitations of the conventional post trauma investigations like FAST and CECT abdomen, it is likely to miss the CBD injury in the early course. MRCP is a good noninvasive investigation to diagnose the biliary injury. ERCP is considered as the most appropriate tool for the diagnosis as well as therapeutic stenting. CONCLUSION: High degree of suspicion is most important in diagnosis of the distal common bile duct trauma as imaging studies like FAST and CT scan can miss the same. MRCP is good noninvasive imaging tool to diagnose the biliary trauma, while ERCP is the best diagnostic and therapeutic tool with minimal post-operative morbidity.

Superior mesenteric artery syndrome in a patient with celiacomesenteric trunk.

Superior mesenteric artery (SMA) syndrome is an uncommon entity leading to compression of the duodenum between the aorta and the SMA. Normally the coeliac trunk and the superior mesenteric arteries have distinct origins from the abdominal aorta. The celiacomesenteric trunk (CMT) is the least frequently reported anatomic variation of all abdominal vascular anomalies. CMT denotes a common trunk of origin of the coeliac and superior mesenteric arteries. The coexistence of these anomalies has never been reported in the literature. We present a case of a 59-year-old man presenting with duodenal obstruction due to SMA syndrome with CMT. The aortomesenteric angle was 13 degrees and SMA-aorta distance was 8 mm. Patient underwent a gastrojejunostomy. After an uneventful recovery, the patient has been symptom free for 1-year follow-up.

Intra-abdominal small intestinal desmoid tumour mimicking GIST.

Desmoid tumours, also known as aggressive fibromatosis, are fibromuscular neoplasms that arise from mesenchymal cell lines. Desmoid tumours are usually benign and are locally aggressive tumours. We report a case of a 31-year-old man presenting with abdominal mass associated with dyspepsia and early satiety. CT scan demonstrated a large heterogeneous mass adherent to or arising from the jejunum. The patient underwent a successful elective exploratory laparotomy with resection of the tumour arising from the wall of the ileum with a 10 cm margin. The patient had an uneventful recovery and no recurrence at 6-month follow-up. Pathology report and immunohistochemistry analysis revealed the mass to be a primary desmoid tumour of the small bowel, as the tumour was negative for c-kit and Discovered on GIST 1 (DOG-1) and positive for beta-catenin and smooth muscle actin.

Glycocalyx disruption enhances motility, proliferation and collagen synthesis in diabetic fibroblasts.

Impaired wound healing represents one of the most debilitating side effects of Diabetes mellitus. Though the role of fibroblasts in wound healing is well-known, the extent to which their function is altered in the context of diabetes remains incompletely understood. Here, we address this question by comparing the phenotypes of healthy dermal fibroblasts (HDFs) and diabetic dermal fibroblasts (DDFs). We show that DDFs are more elongated but less motile and less contractile than HDFs. Reduced motility of DDFs is attributed to formation of larger focal adhesions stabilized by a bulky glycocalyx, associated with increased expression of the cell surface glycoprotein mucin 16 (MUC 16). Disruption of the glycocalyx not only restored DDF motility to levels comparable to that of HDFs, but also led to increased proliferation and collagen synthesis. Collectively, our results illustrate the influence of glycocalyx disruption on mechanics of diabetic fibroblasts relevant to cell motility.

Metastasis of carcinoma of buccal mucosa to small intestine causing ileal perforation.

Oral cancers rarely metastasize to the small intestines. In a previously operated case of squamous cell carcinoma of buccal mucosa without any known preoperative distant metastases, we report a case of solitary ileal perforation 3 months after the surgery. The edge of the ileal perforation was positive for squamous cell carcinoma on histopathology. It is important to remember metastases as a cause of acute abdomen in the prior history of oral malignancies.

Metastasis in mixed epithelial stromal tumour of the kidney: a rare presentation.

Mixed epithelial stromal tumour of the kidney (MESTK) is a rare genitourinary tract tumour. MESTK is typically seen in perimenopausal women and rarely reported in men and children. MESTK has been included in the WHO renal tumour classification since 2004. Here, we present a case of 50-year-old female patient who underwent left radical nephrectomy for left renal mass. Postoperative positron emission tomography (PET) scan also showed nodal metastasis, for which, she was started on chemotherapy.

Salmonella paratyphi A infection presenting as breast abscess.

Salmonella in a breast abscess is uncommon, and Salmonella paratyphi A causing breast abscess is a rare entity. It has been reported post immunosuppression. We report here a 35-year-old woman with breast abscess caused by S. paratyphi A without obvious enteric fever-like symptoms. The case was managed with combined surgical and medical approach to treat the aetiology and focal infection.

Ileocaecal and transverse colonic tuberculosis mimicking colonic malignancy - A case report.

INTRODUCTION: Gastrointestinal tuberculosis is common in the developing world especially in the lower socioeconomic groups. In elderly, it may mimic malignancy. CASE PRESENTATION: A 46-year-old female presented with a 6 month history of diffuse pain in abdomen with low grade fever and loss of weight and appetite. Clinically, differential of malignancy of the large bowel was considered. The computerized tomography(CT) scan of the abdomen revealed a diffuse concentric long segmental thickening of terminal ileum, ileo ceacal junction, ascending colon and narrowing of the transverse colonic end of the splenic flexure suggesting an infective etiology. Colonoscopy showed an ulcero-nodular lesion at the splenic flexure raising the possibility of colonic cancer and thickening of ascending colon and caecum. Colonoscopic biopsy from both sites, on histopathology, showed a moderate mixed inflammation and occasional lymphoid collection and crypt abscesses in the lamina propria giving a differential of tuberculosis or Crohn's disease. Biopsy smear showed occasional acid fast bacilli(AFBs) and the gene Xpert detected mycobacterium tuberculosis(MTB). The patient was started on anti Koch's therapy(AKT). DISCUSSION: In this case the differential diagnosis was malignancy of the colon, inflammatory bowel disease and tuberculosis as all these conditions may have similar clinical profile and radiological findings. Tuberculosis of bowel was considered as the most probable diagnosis due to the CT findings. But the colonoscopy suggested malignant etiology. CONCLUSION: Possibility of tuberculosis should be kept in mind while dealing with synchronous lesions in large intestine.

Gastric outlet obstruction: an unusual case of primary duodenal tuberculosis.

BACKGROUND: Tuberculosis is a major health problem worldwide. Gastrointestinal tuberculosis presenting as isolated involvement of the duodenum is a rare case. CASE PRESENTATION: A 13 year male, presented with features of gastric outlet obstruction. CT enterography scan showed circumferential mural thickening in first and second part of duodenal junction causing luminal narrowing. Upper GI endoscopy confirmed the narrowing of D1-D2 junction. Duodenal biopsy showed duodenitis with negative result for AFB stain, Helicobacter Pylori. Patient underwent roux-en-y gastro-jejunostomy. Histo-pathological findings were consistent with tuberculosis. Patient was started on AKT and discharged. At 3 months follow up; patient asymptomatic. CONCLUSION: The unusual location of gastrointestinal tuberculosis, lack of specific signs and symptoms, radiological studies and endoscopy findings makes diagnosis a challenge. The treatment of duodenal tuberculosis is still medical and surgery should be reserved for emergency like gastric outlet obstruction causing nutritional compromise.

Adenocarcinoma mimicking appendicular lump: a diagnostic dilemma-a case report.

BACKGROUND: Primary appendiceal adenocarcinoma is a rare tumor, mucinous variety being common. This case is reported to highlight the unusual presentation and diagnostic difficulty of appendiceal adenocarcinoma. CASE PRESENTATION: Patient presented with acute appendicitis with ill-defined tender lump which responded to conservative management. CONCLUSIONS: High index of suspicion should be kept in mind for elderly patients presenting with appendicular lump. Every effort should be made during elective appendectomy to remove stump in case of sloughed out appendix.

Study of the occurrence of intra-abdominal hypertension and abdominal compartment syndrome in patients of blunt abdominal trauma and its correlation with the clinical outcome in the above patients.

BACKGROUND: Intra-abdominal pressure (IAP) measurements have been identified as essential for diagnosis and management of both intra-abdominal hypertension (IAH) and Abdominal compartment syndrome (ACS). It has gained prominent status in ICUs worldwide. We aimed to evaluate the utility of measurement of rise in bladder pressure to assess IAP levels in blunt abdominal trauma (BAT) patients. PATIENTS AND METHODS: Thirty patients of BAT with solid organ injuries were included in this study. Intra-abdominal pressure was measured through a Foleys bladder catheter throughout their stay. Bladder pressure was compared with clinical parameters like mean arterial pressures(MAP), respiratory rate(RR), serum creatinine(SC) and abdominal girth(AG) and also with outcome in terms of intervention whether operative(OI) or non-operative(NOI). RESULTS: Bladder pressure showed significant correlation with MAP (R = -0.418; P = 0.022), AG (R = 0.755; P = 0.000), SC (R = 0.689; P = 0.000) and RR (R = 0.537; P = 0.002). Bladder pressure (R = 0.851; P = 0.000), SC (R = 0.625; P = 0.000), MAP (R = -0.350; P = 0.058) and maximum AG difference (R = 0.634; P = 0.000) showed significant correlation with intervention. In total, 17 patients (56 %) required intervention, 9 patients (30 %) underwent NOI (pigtailing or aspiration) while 8 (27 %) needed OI. More than 3 derailed parameters were associated with 100 % intervention (Mean 3.47, SD-1.23). High APACHE III score on admission (>40) was associated with increased intervention (p = 0.001). Intervention correlates well with Grade of injury (p = 0.000) and not with number of organs injured (p = 0.061). Blood transfusion of 2 or more units of blood was associated with increased intervention (p = 0.000). CONCLUSION: Increased bladder pressure and other clinical parameters (MAP, SC, RR and change in AG) correlates well with intervention. Elevated bladder pressure correlates well with other clinical parameters in patients with BAT. Bladder pressure, SC, MAP, RR and AG difference can be used to determine the group of patients that can be managed conservatively and those that would benefit with minimal intervention or exploration. During Non-operative management (NOM) of patients with BAT and multiple solid organ injuries, IAP monitoring may be a simple and objective guideline to suggest further intervention whether NOI or OI. Although routine bladder pressure measurements will result in unnecessary monitoring of large number of patients it is hoped that patients with IAH can be detected early and subsequent ACS with morbid abdominal exploration can be prevented. However the criterion for non-operative failure and the point of decompression needs further refinement to prevent an increase of nontherapeutic operations.

Primary Liver Abscess with Anterior Abdominal Wall Extension Caused by Mycobacteriumtuberculosis Complex.

Tubercular liver abscess is generally secondary to some other primary foci in the body, most notably pulmonary and gastrointestinal system. To find primary tubercular liver abscess is rare, with prevalence of 0.34% in patients with hepatic tuberculosis. Abscess tracking into abdominal wall from spinal and para spinal tuberculosis is known, however primary liver tuberculosis rupturing into anterior abdominal wall has been reported only twice in literature. We report a case of 43-year-old female with direct invasion of the anterior abdominal wall from an isolated tubercular parenchymal liver abscess, caused by Mycobacterium tuberculosis complex, diagnosed primarily on smear for Acid Fast Bacilli (AFB), imaging and isolated by culture and BACTEC MGIT 960 KIT. We discuss here the diagnostic dilemma, management and outcome of primary tubercular liver parenchymal abscess with direct invasion into anterior abdominal wall.

Gastrointestinal stromal tumour presenting as palpable abdominal mass: A rare entity.

Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumour of gastro-intestinal tract. Annual incidence of GIST in United States is approximately 3000-4000. Clinical presentation of GIST varies with location and size of tumour but GIST presenting with palpable abdominal mass is rare. We report a case of 38 years old male who presented with large abdominal lump. Computed tomography (CT) scan showed a large solid-cystic lesion encasing second part of duodenum and distal common bile duct. On CT differential diagnosis of Leiomyoma, Leiomyosarcoma and GIST were made. The diagnosis of GIST was confirmed by immune-histochemical study of the biopsy material. Patient underwent pancreaticodudenectomy. Post-operative course was uneventful. Patient was started on Imatinib therapy post-operatively. No recurrence noted at six months follow up.

Primary hydatid cyst of peritoneum presented as abdominal lump: a rare presentation.

The incidence of primary hydatid cyst of peritoneum is 2%. It can present as a palpable abdominal lump. The differential diagnosis is cystic ovarian tumor clinically and radiologically. Peritoneal hydatid disease should be included in differential diagnosis of sonographically diagnosed pelvic cystic lesion.