Cholecystitis in a midline gallbladder: A rare ectopic location.

INTRODUCTION: The ectopic gallbladder is an uncommonly encountered anomaly that surgeons should be aware of. Its diagnosis is difficult but can be elucidated with the use of computed tomography and MRCP. PRESENTATION OF CASE: We present a case of a 64-year-old patient who presented with abdominal pain, inflammatory epigastric mass and fever. Computed tomography (CT) revealed the presence of a para-umbilical gallbladder with signs of acute cholecystitis. Laparoscopic exploration revealed that the gall bladder was not present in its usual fossa but was seen attached to the midline anterior abdominal wall with extensive adhesion between it and the omentum. Given the complexity of the cholecystectomy via the laparoscopic approach, a conversion to a midline incision was performed. The IOC confirmed the absence of anatomical variants of the biliary tree. DISCUSSION: An ectopic gallbladder is a difficult entity to diagnose as it can create clinical confusion by tampering with the common clinical presentation of cholecystitis. MRCP is currently one of the most effective preoperative examination methods as it detects the coexistence of biliary tract variation. Laparoscopic surgery is a safe procedure to be performed in the ectopic gallbladder. CONCLUSION: Ectopy of the gallbladder is a rare congenital abnormality that should be kept in mind to avoid errors or delays in management.

Hydatid cyst of the liver fistulized into the inferior vena cava.

INTRODUCTION: Fistulization or rupture of hydatid liver cysts to the inferior vena cava (IVC) is an extremely rare and life-threatening condition. PRESENTATION OF CASE: We report the case of a 70-year-old patient who presented with right-upper-quadrant pain and fullness evolving for 03 months. Physical examination showed dilated veins over the anterior abdominal wall and the flanks associated with lower-extremity swelling. Computed tomograph of the abdomen showed a hydatid cyst invading segments VI and VII of the liver fistulized into the inferior vena cava. The IVC was partially trombosed. The diagnosis of a possibly ruptured hydatid cyst in the inferior vena cava was then made. The patient underwent surgical management. Per-operatively the cystic cavity had bloody content but the cysto-vascular communication was not identified. Partial cystectomy was performed leaving a fairly extensive contact between the calcified pericyst and the IVC. The postoperative course was uneventful. DISCUSSION: Rupture of the hepatic hydatid cyst into the IVC is very rare and may lead to fatal pulmonary embolism secondary to the migration of vesicles in the pulmonary artery or haemorrhagic shock. CT scan remains the best investigation method to assess the vascular links of the hepatic hydatid cyst especially with the IVC. Surgical treatment of the hepatic hydatid cyst ruptured into the IVC mandates vascular control before the hydatid cyst is punctured or removed. CONCLUSION: Fistulized hydatid cysts into the IVC should be operated on in centres equipped for extracorporeal bypass techniques, and experienced in the surgery of hepatic echinococcosis.

Acute pancreatitis secondary to ansa pancreatica: Two new cases and review of the literature.

We described two cases of acute pancreatitis secondary to ansa pancreatica. The first patient was diagnosed on MRCP and improved after standard treatment of AP. In the second case, ansa pancreatica was diagnosed on IOP. At the second episode of AP, sphincterotomy of the minor papilla was performed.

Perforated Jejunal Diverticulitis: a rare cause of acute abdominal pain.

It is imperative for surgeons to have a heightened awareness of complications of jejunal diverticular disease so that they can act quickly and contribute to a successful clinical outcome for their patients.

Pedunculated hepatic focal nodular hyperplasia: A case report and review of the literature.

Focal nodular hyperplasia (FNH) is a common asymptomatic benign hepatic tumor encountered in middle-aged women. However, pedunculated FNH is exceedingly rare and more frequently associated with complications. That is why surgical management is mandatory in this form.

Ileocecal and hepatic tuberculosis mimicking a metastatic cecal malignancy: Case report.

We wish to highlight that on encountering a suspicious hepatic and a colonic lesion, the possibility of TB should also be kept in mind apart from the obvious possibility of metastasis of a colonic cancer especially in an endemic country like Tunisia.

Chilaiditi's sign: A rare differential diagnosis of pneumoperitoneum.

Chilaiditi sign is a rare condition typically mistaken for pneumoperitoneum. CT scan can confirm the diagnosis. Its management is conservative that is why it should be well known by surgeons to avoid unnecessary exploratory laparotomies.

Large pedunculated colonic lipoma: a rare cause of colorectal intussusception in adults.

Colo-rectal intussusception is rare in adults and is often secondary to malignant lesions, rarely benign lesions such as colonic lipomas can also be the cause. We present the case a 60-year-old man who presented to the emergency department with acute abdominal pain. On physical examination, the abdomen was distended with diffuse tenderness. CT scan of the abdomen revealed a colo-rectal intussusception secondary to a rectal lipoma with parietal pneumatosis of the invaginated loop. An emergency laparotomy was performed. Intraoperatively the radiological findings were confirmed. A rectosigmoid resection (Hartmann's procedure) taking off the lipoma and the invaginated segment of the colon was performed and the patient had an unevent full recovery. Histopathology confirmed a 6cm sub-mucosal lipoma without evidence of malignancy. As the diagnosis of a benign disease in patients presenting with colonic intussusception can only be made on pathological examination, this entity should be managed as a malignant lesion due to the high incidence of malignancy.

Surgical management of groove pancreatitis: a case report.

Groove pancreatitis (GP) is a rare form of chronic pancreatitis involving the groove area bound by the pancreatic head, the duodenum, and the common bile duct. The diagnosis of this entity is challenging since it can mimic pancreatic carcinoma. We herein report the case of groove pancreatitis diagnosed in a 37 year old men, with a past history of chronic alcohol consumption. The patient was admitted for several times over the past three years because of recurrent alcohol-induced pancreatitis. The diagnosis of groove pancreatitis was made on the basis of CT, MRI and EUS findings. A medical treatment was initially attempted. In the absence of improvement in clinical symptoms, a pancreatico-duodenectomy was performed with satisfying results at 24 months follow up. Pancreatico-duodenectomy is the treatment of choice in groove pancreatitis since it leads to total resolution of clinical symptoms.

Primary hydatic cyst of the fallopian tube.

Hydatid disease is endemic in Tunisia. The involvement of the female genital tract is uncommon, and the occurrence in the fallopian tube is exceptional. We present a case of a 42-year-old woman who had complained of a 4-month history of lower abdominal pain. The abdominal ultrasonography and CT scan showed a multiloculated cystic lesion in the left adnexa. The exploratory laparotomy found a cystic mass developing in the left fallopian tube. Left salpingectomy was performed. The pathological examination confirmed the diagnosis of hydatid cyst disease. No recurrence was detected at the 2-year follow-up. Tubal hydatid cyst is an extremely rare condition that should be considered in the differential diagnosis of any cystic lesion in patients from endemic areas.

Gallbladder agenesis in the elderly: a diagnostic challenge.

Gallbladder agenesis (GA) is a rare congenital malformation characterized by the absence of the gallbladder and cystic duct due to an anomaly in the embryonic development. It is commonly associated with other congenital abnormalities, and the isolated form is extremely rare. Its clinical presentation is variable. Actually, GA is more often incidentally diagnosed. Magnetic resonance cholangiopancreatography (MRCP) is considered to be the diagnosis method of choice since it avoids unnecessary and risky surgery in symptomatic patients. Here we report the case of a radiologically incidentally discovered gallbladder agenesis in a 68-year-old patient.