Duodenal stricture secondary to IgG4-related chronic sclerosing duodenitis-A case report with review of the literature.

Key Clinical Message: This case highlights the importance of a definite diagnosis of an IgG4-related chronic sclerosing duodenitis based on histological and radiological findings to rule out any malignancy in the mass. While dealing with patients having concentric duodenal thickening resulting in stricture formation, one should think of inflammatory etiology as well. IgG4-related disease is one of these inflammatory disorders where we see soft tissue thickening without a large mass or any associated lymphadenopathy as in our case. Abstract: Immunoglobulin G4-related disease (IgG4-RD) is distinguished as an infiltration of IgG-4-positive plasmacytes involving inflammatory lesions across multiple organs which is accompanied by raised IgG4 levels in the serum. Several inflammatory disorders are recognized as part of the IgG4-RD family based on shared histopathological features, which include Mikulicz's disease, chronic sclerosing sialadenitis, or Riedel's thyroiditis. Our case highlights a distinctive presentation of IgG4-related diseases; a 58-year-old man presenting with duodenal stricture highly suspicious of a duodenal mass/ampullary mass later found to be due to IgG4-related sclerosing duodenitis with negative malignancy on biopsy. We present the diagnostic challenges faced and relevant findings noted.

Pseudoaneurysm of cystic artery stump after laparoscopic cholecystectomy managed successfully with branch hepatic artery embolization using jail technique.

An unusual manifestation caused by cholecystitis, infection, or iatrogenic damage after cholecystectomy is a pseudoaneurysm of the cystic artery. We report this rare illness in a 64-year-old man who visited the emergency room with hematemesis and anemia. The patient initially experienced acute cholecystitis and then underwent a laparoscopic cholecystectomy following which he developed a cystic artery pseudoaneurysm, secondary to infected fluid collection. Based on the patient's history and contrast-enhanced computer tomography abdomen, a diagnosis of pseudoaneurysm of the cystic artery was made. Angioembolization of the hepatic artery branch was performed to occlude the pseudoaneurysm.

IgG4-related inflammatory pancreatic head pseudotumor mirrors pancreatic head tumor: A novel case series with a review of the literature.

Key Clinical Message: In this noteworthy case series regarding pancreatic pseudo tumors, we intend to spread knowledge among physicians for the diagnostic and therapeutic approach and eventual disease prognosis. Abstract: Inflammatory pseudotumor of pancreatic head greatly mimics pancreatic head tumor. One of them is IgG4-related pancreatic disease, which is commonly mistaken as neoplastic disease on imaging. In our novel case series, we report three cases of IgG4-related pancreatic head pseudotumor with patients ranging from 35 to 72 years of age. Patients presented with jaundice and abdominal pain. Alongside initial laboratory workup, abdominal CTs and serum IgG4 levels were also obtained. Imaging features in conjunction with IgG4 levels confirmed the diagnosis of IgG4-related autoimmune pancreatitis. Pancreatic pseudotumors are notorious for being often reported as real tumors. Through our noteworthy case series, we intend to highlight the imaging features and laboratory markers that are crucial in such cases to avoid invasive procedures.

Use of National Institute for Health and Care Excellence head injury guidelines among patients with delayed presentation after head trauma can lead to missed traumatic brain injury: a 5-year institutional review.

Introduction: In 2014, traumatic brain injury (TBI) caused 3 million ER visits, hospitalizations, and deaths in the US. The National Institute for Health and Care Excellence (NICE) guidelines, initially generated using data from patients presenting within 24 h of head trauma, are used to determine the need for head computed tomography (CT) scan in patients after 24 h. The authors wanted to determine the proportion of CT scans for head trauma performed at our center in late presenters (>24 h after head trauma), the incidence of intracranial pathology in early (24 h) versus late (>24 h) presenters, and the sensitivity of the NICE guidelines for TBI in these two subpopulations. Methods: A retrospective chart review was conducted at a tertiary care center in Karachi. All people (>16) who had a head CT for head trauma from 2010 to 2015 were included. Age, sex, primary diagnosis, comorbid disorders, mechanism-of-injury, duration (in hours) from head trauma to presentation, site, and extent of injury (injury severity scale), hospital stay, number and details of surgical procedures, CT scan findings, other injuries, and mortality were recorded. Means were compared using the Independent Sample t-test, while categorical variables were compared using χ2. Multivariate logistic regression analyses were used to identify TBI predictors. Results: The authors found 2009 eligible patients; seven were excluded due to incomplete medical records. The final statistical analysis comprised 2002 head trauma patients. Overall, 52% of early and late presenters had severe injuries, and 2.3% died. 32.2% of patients with head trauma had CT after 24 h. Early presenters were 46.7% traumatized, while late presenters were 63%. The NICE guidelines were 93% sensitive for early presenters and 83% for late presenters with traumatic intracranial injury. Conclusion: Patients coming to the emergency department after 24 h of head trauma are a large proportion of the overall head trauma population. The NICE guidelines for late-presenting head injuries are less sensitive and may overlook intracranial injuries if imaging is not performed.

Hydatid disease of central nervous system, a clinicopathological study of 33 cases.

Objectives: Involvement of central nervous system (CNS) by Hydatid cyst is rare comprising 0.5-4% of all hydatid cysts and principally affecting those younger than 20 years, giving rise to cystic masses mostly in the cerebral hemispheres. To report the clinicopathological findings of CNS hydatid cysts, we diagnosed and review the findings of the previous studies. Materials and Methods: All cases reported in our Section between January 1, 2001, and June 30, 2022, were included in the study. By searching our files, cases were retrieved, and diagnosis was confirmed. Follow-up was received on telephone. Ethical exemption was obtained. Results: Thirty-three cases were diagnosed. Almost all were received from rural areas. There were 17 females and 16 males. Mean and median age were 20 and 19 years, respectively. Over 60% were younger than 20 years of age. All 33 involved the cerebral and cerebellar hemispheres. Seventy six percent were supratentorial while 24% were infratentorial. The most common signs and symptoms included weakness, headaches, and seizures. All appeared as solitary cystic masses on imaging. Almost 67% were clinically suspected to be hydatid cysts. Grossly, thin-walled transparent unilocular or multilocular cysts filled with viscous material were received intact in 52% and in multiple pieces in 48% cases. Intact cysts measured 7 cm on average. All demonstrated typical histology. Of the nine patients whose follow-up was available, one died from unspecified acute surgery related complications. Four patients were asymptomatic at the time of follow-up, whereas four developed recurrent cysts. All eight received albendazole therapy. Conclusion: Cerebellum/posterior fossa location was common. Several cases were received in multiple pieces with increased risk of recurrence. Clinicopathological features were similar to those reported in literature. This series will hopefully serve to increase awareness regarding CNS hydatid disease.

Testicular choriocarcinoma with small bowel metastasis and active gastrointestinal bleeding.

Testicular choriocarcinomas make up less than 1% of all germ-cell tumors and are highly malignant, attributable to hematogenous spread. While the most common sites of metastasis are the lungs and liver, metastatic spread to the gastrointestinal tract is rare wherein patients may present with GI distress or even an upper GI bleed. In this report, we present a case of known testicular choriocarcinoma in a 40-year-old male who presented to the emergency room with severe anemia and a suspected upper GI bleed.

Spontaneous Uterine Rupture Secondary to Morbidly Adherent Placenta in an Unscarred Uterus.

We report a case of spontaneous uterine rupture in a primigravida with an unscarred uterus, which was secondary to morbidly adherent placenta proven on surgery and histology. Although rare, uterine rupture should be considered as a differential diagnosis of acute abdominal pain in pregnancies, especially when associated with free fluid, even with the absence of vaginal bleeding. Abnormal placentation is associated with spontaneous antepartum uterine rupture even in early pregnancy. Most cases in the literature have advocated emergency hysterectomy to arrest life-threatening hemorrhage.

The Characteristics of Appendicoliths Associated with Acute Appendicitis.

Introduction Differences between appendicoliths associated with appendicitis and those found incidentally have not been studied. The objective of this study was to determine the characteristics of appendicoliths that are associated with acute appendicitis. Methods A cross-sectional study of patients with appendicoliths identified on computed tomographic (CT) scan from January 2008 till December 2014 was conducted. Patients were divided into two group: appendicitis and appendicoliths (AA) and incidentally discovered appendicoliths (IA). Results Overall, 321 patients were included in the study. Of these, 103 (32%) patients were in the AA group while 218 (68%) patients were in the IA group. Both groups were similar in age and gender distribution. Significantly greater proportion of patients in the AA group had more than one appendicolith [AA vs. IA: 63 (62%) vs. 82 (38%), p < 0.001], appendicolith location at the base [AA vs. IA: 34 (33%) vs. 33 (15%), p < 0.001] and appendicolith diameter of 5 mm or more [AA vs. IA: 71 (69%) vs. 28 (13%), p < 0.001]. On multivariate analysis, more than one appendicolith [Odds ratio (OR): 1.9, 95% CI: 1.1-3.4; p = 0.02] and diameter of 5 mm or more (OR: 13, 95% CI: 7.1-23.6; p < 0.001) were independently associated with acute appendicitis. Conclusion Multiple appendicoliths and appendicoliths larger than 5 mm are associated with acute appendicitis.

Primary esophageal tuberculosis mimicking esophageal carcinoma on computed tomography: A case report.

BACKGROUND: Tuberculosis (TB) has a rare extrapulmonary manifestation known as esophageal tuberculosis, accounting for 0.2% of total TB patients. Esophageal TB typically presents with dysphagia, with retrosternal pain or odynophagia, but generalized symptoms such as low-grade fever, decreased appetite, and weight loss are also observed. Esophageal carcinoma and Crohn's disease of the esophagus are important differential diagnoses with similar presentation. CASE SUMMARY: We present a case of a 25-year-old male, who presented with esophageal TB mimicking an esophageal carcinoma. Lab work-up, Mantoux test, and chest X-ray were normal. Barium-swallow examination showed moderate dilatation of distal esophagus with a nodular and irregular mucosa. Computed tomography showed significant thickening of thoracic and distal esophagus with infiltration into the lesser omentum and large, centrally necrotic lymph nodes on gastro-hepatic ligament suggestive of a possible malignancy. Esophagoscopy was performed and a biopsy of mural thickening was performed and sent for histopathological examination. The histopathology report and TB-polymerase chain reaction confirmed the diagnosis of esophageal TB. The patient was started on anti-tuberculous therapy (ATT), and complete resolution of symptoms and disease was achieved in 6 mo. CONCLUSION: Esophageal TB is an extremely rare, yet important differential diagnosis in a patient presenting with dysphagia. Esophageal TB can mimic esophageal carcinoma on computed tomography scan. The patient responded well to a complete course of ATT.

Cholecystocolonic Fistula.

Cholecystocolonic fistula (CCF) is a rare complication of gallstone disease with a variable clinical presentation. It is difficult to diagnose CCF pre-operatively despite modern diagnostic and imaging modalities as they are often asymptomatic or incidentally discovered, often peri-operatively. However, management of this uncommon yet important finding is not very well described in the literature. The most common fistula is the cholecystoduodenal fistula, followed by the cholecystocolonic fistula; the cholecystogastric fistula is reportedly the least commonly reported. We report our experience with three cases of cholecystocolonic fistula discovered on imaging which were subsequently confirmed through surgery.

Pure Uterine Lipoma on 18FDG PET/CT: Rare But Easy to Diagnose.

Tumors of the uterus are extremely uncommon. Pure lipomas of the uterus are very rare, and only a few cases have been reported. We are presenting a case of a post-menopausal lady, a survivor of right breast cancer who had an 18 F-fluorodeoxyglucose positron emission tomography/computed tomography (18FDG PET/CT) for evaluation of a suspected right lung nodule. The scan was negative for hypermetabolic abnormality. However, a hypodense and non-metabolic lesion was seen in the fundus of the uterus. On subsequent hysterectomy, it was found to be a pure lipoma.

Risk of appendicitis in patients with incidentally discovered appendicoliths.

BACKGROUND: An appendicolith-related appendiceal obstruction leading to appendicitis is a commonly encountered surgical emergency that has clear evidence-based management plans. However, there is no consensus on management of asymptomatic patients when appendicoliths are found incidentally. The objective of this study was to determine the risk of appendicitis in patients with an incidental finding of the appendicolith. METHODS: A retrospective matched cohort study of patients with appendicolith discovered incidentally on computed tomographic scan from January 2008 to December 2014 at our institution was completed. The size and position of the appendicolith were ascertained. The study group was matched by age and gender to a control group. Both groups were contacted and interviewed regarding development of appendicitis. RESULTS: In total, 111 patients with appendicolith were successfully contacted and included in the study. Mean age was found to be 38 ± 15 y with 36 (32%) of the study population being females. Mean length of appendix was 66 ± 16 mm, and mean width was 5.8 ± 0.9 mm. Mean size of the appendicolith was 3.6 ± 1.1 mm (1.4-7.8 mm). Fifty-eight percent of appendicoliths was located at the proximal end or whole of appendix, 31% at mid area, and 11% at the distal end of appendix. All patients of the study and control groups were contacted, and at a mean follow-up of 4.0 ± 1.7 y, there was no occurrence of acute appendicitis in either group. CONCLUSIONS: Patients with incidentally discovered appendicolith on radiological imaging did not develop appendicitis. Hence, the risk of developing acute appendicitis for these patients does not seem higher than the general population.

Intrahepatic biliary cystadenoma mimicking hydatid cyst of liver: a clinicopathologic study of six cases.

BACKGROUND: Intrahepatic biliary cystadenomas are rare hepatic neoplasms, which are usually cystic. These tumors are often misdiagnosed as simple liver cysts and hydatid cysts clinically and radiologically owing to nonspecific clinical and radiologic features. These tumors require complete resection, as recurrence and malignant transformation can occur following incomplete excision. It is essential that these tumors be diagnosed accurately so that they can be adequately excised. METHODS: Clinical and radiological features of six cases of biliary cystadenoma are described. RESULTS: All of these cases were resected with the clinical and/or radiological impression of simple liver cysts and/or hydatid cysts. Out of the six patients, five were female and one was male. Ages of the patients ranged from 28 to 60 years (mean 45 years). The patients presented with nonspecific symptoms. Internal septations were seen on preoperative imaging (when available). On gross examination, all tumors were cystic; their sizes varied from 5.5 to 14 cm, mean size was 9.0 cm. On histopathologic examination, cystic spaces were lined by cuboidal to columnar mucin-secreting epithelium with underlying ovarian-type stroma. In one case, ovarian-type stroma was not seen. Recurrence was seen in three cases at 1 to 5 years of follow up. CONCLUSIONS: Owing to their malignant potential and high recurrence rate following incomplete resection, an aggressive surgical approach is recommended. Prognosis is excellent after complete resection.

Autoimmune Disease Presenting As Acute Abdomen.

Mesenteric vasculitis and resultant bowel ischemia is rare but serious complication of autoimmune disorders. Early detection and treatment is the key to avoid potentially fatal outcomes of bowel perforation and peritonitis. In this series, we present patients presenting with acute abdominal pain and having CT imaging features of bowel ischemia who responded well to immunosuppressive therapy. The aim of this work is to familiarize health professionals with possibility and imaging features of mesenteric vasculitis.

Papillary craniopharyngioma: A clinicopathologic study of a rare entity from a major tertiary care center in Pakistan.

BACKGROUND: Papillary craniopharyngioma (PCP) are uncommon variants of craniopharyngiomas (CP), which are benign epithelial neoplasms of the sellar and suprasellar region. Histologically, PCPs are typically composed of well-differentiated stratified squamous epithelium; however, focal variations are not uncommon. A distinction from other lesions of the region, despite being difficult to achieve due to the overlapping radiological and clinical features, is important for adequate treatment to be administered. OBJECTIVE: Our aim was to study the clinical and histological features of PCP with emphasis on features that are helpful in its distinction from other lesions that are similar in appearance. MATERIALS AND METHODS: We reviewed 13 cases of PCP diagnosed in our institution between January 2010 and December 2015. RESULTS: The mean age at presentation was 30.76 years. Two of the patients belonged to the pediatric age group. Male-to-female ratio was 2.25:1. Suprasellar location (either alone or in combination with sellar region) was the most common tumor site. Microscopically, all of the cases showed stratified squamous epithelium with frequent pseudopapillae formation. Focal adamantinomatous epithelium and columnar epithelium with variable cilia and goblet cells were seen in 4 (30.7%) cases. Brain invasion was observed in 3 (23%) cases. Four patients died of their disease; 2 of the 7 patients with an available follow up, developed recurrences; and, 5 experienced severe postoperative morbidity. CONCLUSION: Majority of the PCPs exhibited typical features with minor variations. Knowledge of the variations in histologic features helps in reaching the correct diagnosis. These tumors can behave aggressively with a high recurrence rate and decreased overall survival.

Isolated Gastric Tuberculosis Mimicking Malignancy.

Isolated tuberculosis of upper gastrointestinal tract is a rare pathology, often mimicking malignancy in clinical presentation and radiological features. We present a case of middle aged gentleman with isolated tuberculosis of stomach, proven on histopathology and showing remarkable improvement on follow up.

TESTICULAR LIPOMATOSIS IN COWDEN DISEASE.

Cowden disease is a genetic syndrome resulting in formation of multiple premalignant hamartomas in different parts of the body with classical radiological features. In this report a case of Testicular Lipomatosis as a result of Cowden disease resulting in primary infertility.