Right-sided strangulating diaphragmatic hernia in an adult without history of trauma: a case report

Background Diaphragmatic hernia involves protrusion of abdominal contents into the thorax through a defect in the diaphragm. This defect can be caused either by developmental failure of the posterolateral foramina to fuse properly, or by traumatic injury of the diaphragm. Left-sided diaphragmatic hernias are more common (80–90%) because the right pleuroperitoneal canal closes earlier and the liver protects the right diaphragm. Diaphragmatic hernias in adults are relatively asymptomatic, but in some cases may lead to incarcerated bowel, intraabdominal organ dysfunction, or severe pulmonary disease. The aim of this report is to enlighten clinical doctors about this rare entity that can have fatal consequences for the patient. Case presentation We present a rare case of a right-sided strangulating diaphragmatic hernia in an adult Caucasian patient without history of trauma. Clinical examination revealed bowel sounds in the right hemithorax, which were confirmed by the presence of loops of small intestine into the right part of the thorax through the right diaphragm, as was shown on chest X-ray and computerized tomography. Deterioration of the clinical status of the patient led to an operation, which revealed strangulated necrotic small bowel. Approximately 1 m of bowel was removed, and laterolateral anastomosis was performed. The patient had an uneventful postoperative recovery and was discharged 8 days later. Conclusions Surgery is required to replace emerged organs into the abdomen and to repair diaphragmatic lesion. A delayed approach can have catastrophic complications for a patient.

Management of acute cholecystitis in patient with cyclic neutropenia: a case report

Background Cyclic neutropenia is a disease that causes a neutropenic decrease in peripheral blood in a cycle of about 21 days. It is a rare hereditary disorder with an estimated incidence of 0.5–1 cases per million population. The absolute neutrophil count can drop to zero, and neutropenic nadir may last for 3–5 days. This is a rare disease, and there are few reports of abdominal surgery in cyclic neutropenia patients; thus, we report this case of neutrophil count fluctuation and perioperative management. Case presentation A 31-year-old man with cyclic neutropenia was transferred to our hospital complaining of right season rib pain, but no rebound tenderness. His C-reactive protein was elevated (4.37 mg/L) and computed tomography revealed a large number of small stones in the gallbladder body and an incarceration in the gallbladder neck. He was diagnosed with acute cholecystitis. Ideally, surgical intervention should have been performed immediately, but because his neutrophil count was 300/μL, endoscopic naso-gallbladder drainage was performed and he was provided antibiotics until his neutrophil count increased to acceptable levels. Three days after admission, his neutrophil count had increased and laparoscopic cholecystectomy was performed. For one week after the operation, antibiotics were administered; he had an uneventful postoperative recovery. He was discharged on the seventh postoperative day and provided an oral antibiotic. Conclusions Infection can be serious in patients with cyclic neutropenia, and it is therefore, important to determine the timing of surgery and to apply appropriate perioperative management with drainage and antibiotic administration.

Laparoscopic colectomy in idiopathic colonic varices: a safe endeavour

A 32-year-old man presented to the emergency department with recurrent episodes of haematochezia and haemodynamic instability. He had no complaints of alteration in bowel habits or mucus discharge in the stool. He was a non-smoker and does not consume alcohol. After stabilising the patient, clinical evaluation and investigations with gastrointestinal endoscopy revealed dilated and tortuous submucosal veins involving the entire colon excepting the distal sigmoid. CT angiography and Doppler ultrasonography revealed normal patency and flow in the mesenteric vessels as well as hepatic, portal vein and inferior vena cava. With the exclusion of the secondary causes, we made the diagnosis of the rare entity of idiopathic colonic varices. He underwent a laparoscopic colectomy with ileorectal anastomosis, without any additional technical challenges intra-op and had an uneventful postoperative recovery. Idiopathic colonic varices can be a differential diagnosis of gastrointestinal bleeding and one can safely proceed with laparoscopic colectomy.

Rudimentary Horn Pregnancy Diagnosed after Laparotomy

Müllerian abnormalities are present in 0.17% of fertile women and 3.5% of infertile women, and a unicornuate uterus is observed in 0.4% of women. The uterus is normally formed during embryogenesis by the fusion of the two Müllerian ducts. If one of the ducts does not develop, only one Müllerian duct contributes to the uterine development. We report a case of Gravida II, abortion I referred from a primary hospital with a referral paper and sonography stating she had IUFD. She had regular antenatal care follow-up at the primary hospital and had 8 months of amenorrhea. Our ultrasound assessment confirmed the intrauterine fetal demise, but the rudimentary horn pregnancy was missed. Repeated attempts at the induction of labor were tried but unsuccessful. The diagnosis was confirmed at laparotomy. She underwent cesarean section with right intact rudimentary horn removal. A nonviable male fetus with birth weight of 1.2 kg was delivered. Women with this abnormality are asymptomatic and unaware of having a unicornuate uterus. Abdominal pain is the most common presenting symptom with the rudimentary horn, but communicating horn pregnancy is generally asymptomatic in early pregnancy. Early awareness of this rare clinical condition is so crucial especially in developing countries where the availability of new technologies is scarce to explore uterine abnormalities. The patient had uneventful postoperative recovery and was discharged after 3 postoperative days.

Hepatoblastoma in an 18- Year Old Female; Rare Entity

Hepatoblastoma is a rare malignant hepatic tumor in adults. It is associated with poor prognosis as it is usually diagnosed late when the tumor is completely unresectable. Presented here, is a case of an 18-year old female with pain abdomen, vomiting, and mass over the right hypochondriac region for one month. CT scan revealed soft tissue density mass on the right lobe of liver suggestive of focal nodular hyperplasia with differential diagnosis of atypical hemangioma. Liver angiography also suggested a vascular tumor of giant hemangioma with inferior exophytic extension. The patient underwent a right extended hepatectomy. Histopathological examination revealed hepatoblastoma with predominant fetal pattern and small focal areas of embryonal pattern. The patient had an uneventful postoperative recovery and is currently undergoing chemotherapy. We present this case for its rarity and ability to masquerade other primary liver tumors in the adult age as seen in our patient.

Growing Skull Fracture of Temporal Bone in Adults: A Case Report and Literature Review

Growing skull fracture (GSF) is an uncommon post-traumatic complication, which accounts for approximately 0.05% to 1% of all skull fractures. Delayed diagnosis of GSF in adulthood is rare and often involved with a variety of neurological symptoms. Here, we reported an adult patient, with an interval of 17 years from initial head trauma to first diagnosis of GSF. The patient complained of short periods of fainting and bilateral visual hallucinations, with a hard palpable bulge around his right occipitomastoid suture region. Computed tomographic imaging demonstrated an arachnoid cyst extending into right mastoid cavity. Consequently, the delayed diagnosis of GSF was confirmed, and the patient was managed with duroplasty and cranioplasty. At the 8-month follow-up, the patient showed an uneventful postoperative recovery. A comprehensive literature review was also conducted, and a total of 70 GSF cases were identified and summarized. According to the literature review, patients with GSF generally have a history of head trauma in their childhood, and delayed diagnosis is a common situation. Diagnosis of GSF should include complete retrospective medical history, physical, and imaging examinations. Once the diagnosis is confirmed, cranioplasty accompanied with duroplasty might be the most effective way to relieve symptoms and prevent further damage.

Reversed Bowel Rotation with Midgut Volvulus and Internal Hernia

Congenital intestinal malrotation is a group of intestinal rotational anomalies occurring during embryogenesis. Reversed rotation is considered the rarest type of malrotation and often presents with symptoms of bowel obstruction. We present a rare case of a 27-year-old woman who presented with acute abdomen. The patient’s preoperative computed tomography (CT) scan and operative findings confirmed reverse malrotation, internal hernia of foramen of Winslow, and midgut volvulus. The transverse colon, duodenum, small bowel, cecum, and appendix were abnormally located, with the presence of Ladd bands. The patient underwent an emergency laparotomy (Ladd procedure) with an uneventful postoperative recovery and an unremarkable follow-up CT scan of the abdomen. A review of the literature for intestinal reverse malrotation is also presented to provide an understanding of the expected clinical picture and imaging findings for this rare anomaly.

A case of postmenopausal bleeding with an unusual finding

Authors report the case of a 55-year-old patient who presented with postmenopausal bleeding. On clinical evaluation uterus was 12 weeks size with a left sided adnexal cystic mass of 8 × 6 cm size. Further imaging studies revealed uterus size of 11.5 × 6.7 × 6.3 cm, left ovarian mass of size 8.4 × 6.7 × 6 cm and endometrial thickness of 17 mm on ultrasonography. She underwent endometrial biopsy to exclude endometrial cancer. The report of which came to be endometrial hyperplasia without atypia. Further MRI study confirmed the findings of USG of a complex cystic lesion of left adnexa 75 × 57 × 60 mm. Tumor marker for ovarian tumors were sent and inhibin B was found to be markedly raised. A provisional diagnosis of GCT (Granulosa cell tumour) was made and staging laparotomy was done. The uterus was found to be 12 × 8 cm size and a left sided ovarian cyst of 8-9 cm size with smooth wall and intact capsule was found. Patient had an uneventful postoperative recovery.

Incidental giant cystic pheochromocytoma: a case report and review of the literature

Introduction Pheochromocytoma is a tumour arising from the adrenal medulla, which secretes catecholamines. Approximately 20% of pheochromocytomas are cystic and more likely to be asymptomatic. They should be surgically resected as all have a malignant potential and pose cardiovascular risk. Case presentation: We report the case of a 61-year-old female patient admitted electively for laparoscopic adrenalectomy for a large cystic pheochromocytoma detected incidentally. Diagnosis was confirmed preoperatively by elevated 24-h urinary metanephrines. The patient was treated preoperatively with alpha and beta blockade. Surgery was without complication; she had an uneventful postoperative recovery and no evidence of recurrence at one-year follow-up. Conclusion This case highlights the necessity of investigating for biochemical function in all adrenal lesions by measuring metanephrines, even when entirely cystic on imaging. Given the surgical and anaesthetic risk in resection of pheochromocytoma, attaining a preoperative diagnosis allows for careful preoperative planning and safe surgery.

Comparison between the draf IIc and standard draf IIb procedure for frontal sinus drainage: single center experience and comparison of outcomes

Aims: Inadequate surgical frontal sinus drainage in chronic sinusitis cases refractory to conservative treatment results in a poor clinical response and is associated with recurrent frontal recess stenosis. Endonasal frontal sinus drainage procedures are classified according to Draf into three groups: DrafIIb enables unilateral orbit to septum drainage and the IIc is the extension of the IIb across the midline. The purpose of our report is to review chronic sinusitis cases treated at our Department using the standard (IIb) or modified (IIc) procedure and compare results. Methods: Patient- and surgery-related data were retrieved on patients operated between 2013 and 2016 for chronic frontal sinusitis using the standard/modified DrafIIb procedure.The modified IIb (i.e. IIc) procedure was performed so that both frontal sinus ostia were visualized by performing an intersinusseptectomy: the aim was to provide drainage to both frontal sinuses simultaneously. Results: In the observed period, 26 patients were treated: 12 using the modified DrafIIb (IIc) and 14 using the standard DrafIIb procedure. There were no significant differences between groups regarding age, sex, number of previous procedures or follow-up period. All patients had an uneventful postoperative recovery and there were no cases of re-stenosis observed in the DrafIIc group; there were seven cases of restenosis in the DrafIIb group.