Forensic medical evaluation of an isolated injury of the small bowel mesentery and its vessels (literature review extended with expert case report)

This work summarizes information from the modern scientific literature devoted to the issues of morphology and mechanisms of an isolated mesenteric injury, which is rare in expert practice. Apart from classic forensic medical papers, publications over 2000 – 2020, devoted to abdominal organ injuries, were analyzed. In the search engines PUBMED and eLibrary.ru, a selection of sources was made according to the keywords: “rupture of the mesenteric root of the small intestine,” “diagnostics,” “forensic medical evaluation.” The results of the literature analysis were used in the study of the repeated forensic medical examination materials of a case of rapid death (in 1.5 hours) due to a traumatic rupture of the mesentery of the small bowel and its large vessels. The combined analysis of the expert case report and special scientific literature allows us to devise the following conclusions: 1. A forensic expert must have expert knowledge in the normal anatomy of the abdominal aorta’s unpaired vessels and their accompanying veins location and know about their variable topographic and anatomical features. 2. Life-threatening bleeding from the damaged vessel of the mesentery of the small bowel occurs in a wide time interval after the mechanical damage. 3. The development of life-threatening intra-abdominal bleeding is due to the scope of damage and the rate of blood flow from the damaged vessel. 4. Thorough examination of the area of rupture of the mesenteric vessel and the state of the tissues in the circumference of the rupture allow to establish the mechanism of injury. 5. Ignorance of the mechanism of injury and specifics of the formation of injuries is the cause of expert errors and scientifically unfounded conclusions. 6. There is no reference material on the rate of blood flow from a damaged large vessel.

Thoracic Splenosis Mimicking Metastatic Neuroendocrine Tumor (NET)

A 64-year-old man presented with abdominal pain. CT scan showed a 5mm left ureter stone, mesenteric root mass as well as a left lung pleuralbased lesion. Metastatic Neuroendocrine Tumor (NET) was suspected, hence a Gallium-68 Dotatate PET was performed. It showed intense uptake in the mesenteric mass, as well as in the pleural nodule, and no intense uptake in the liver. The liver is the most common site for small bowel NET metastasis. It is unusual to have pleural metastasis without liver metastasis. A review of this patient’s past medical history revealed a motor vehicle accident 20 years ago which required an exploratory laparotomy and splenectomy. Gallium 68 Dotatate PET scan can detect splenosis because it has somatostatin receptors. In patients with an existing neoplasm, metastases should be ruled out before confirming the diagnosis of splenosis. CT-guided biopsy of pleura nodule was performed, which confirmed the diagnosis of splenosis.

Suture granuloma mimicking local recurrence of colon cancer after open right hemicolectomy: a case report

Background Foreign body granuloma is a rare surgery-related complication that can masquerade as cancer recurrence during postoperative surveillance. It may therefore deceive clinicians and lead to unnecessary interventions. The case presented herein demonstrates how a foreign body granuloma can be misleading in preoperative radiological studies and why this condition should not be ignored in differential diagnoses during surveillance of patients with previous history of abdominal surgery of any kind. Case presentation We report a case of suture granuloma mistaken for recurrent colon cancer, including the clinical history, imaging data, and histopathological photographs. A 60-year-old man was followed up at our institution after open right hemicolectomy 2 years earlier for ascending colon carcinoma. Contrast-enhanced computed tomography and magnetic resonance imaging revealed an infiltrative heterogeneous soft tissue lesion at the right mesenteric root, adjacent to the ileocolic anastomosis. Local recurrence was therefore suspected. We performed exploratory laparotomy, excised the tumor, and sent it for histopathological examination, which confirmed suture granuloma. Conclusions Foreign body granuloma is a rare surgery-related complication that should be considered during surveillance following colectomy. Its radiological features may mimic recurrent lesions, thus misleading clinicians and causing unnecessary interventions or further complications.

Intrauterine midgut volvulus as a rare cause of intestinal obstruction: a case report

Background Intrauterine midgut volvulus is a very rare, life-threatening condition, and prenatal diagnosis is difficult. In this article, we present a case of midgut volvulus followed by a pre-diagnosis of antenatal jejunal atresia. Case presentation A 1-day-old Turkish male baby, who was followed with a diagnosis of antenatal jejunal atresia, with a birth weight of 3600 g, delivered by cesarean section at 38 weeks of gestation from a 19-year-old mother in her fourth pregnancy, was taken to the newborn intensive care unit. The patient underwent surgery on the postnatal first day with a preliminary diagnosis of jejunal atresia. It was observed that the small intestine was rotated two full cycles from the mesenteric root. Bowel blood circulation was good. Volvulus was untwisted. There was malrotation. Ladd's procedure was performed. The baby was discharged on the seventh postoperative day with full oral feeding. The patient is still in the first postoperative year and follow-up has been uneventful. Conclusion Intrauterine midgut volvulus has been associated with high mortality in the literature. Differential diagnosis of midgut volvulus in patients with antenatal intestinal obstruction, close prenatal follow-up, appropriate delivery and timing of surgical intervention may significantly reduce morbidity and mortality.

Review of the theories of gastroschisis pathogenesis

Gastroschisis and omphalocele are the most common congenital malformations of the abdominal wall that required surgical correction. Despite of the long history of the gastroschisis’ study, there is no generally accepted theory of the pathogenesis of this malformation. There are numerous theories of the pathogenesis of gastroschisis discussed in the modern literature: disorders of differentiation of embrionic mesenchyme as the result of teratogenic influence on the early stages of the embryonic development; rupture of amniotic membrane at the base of the umbilical cord; vascular disorders during of the embryonic development; disorders of the yolk-sac escape. Each of existing theories has its supporters and opponents. It is no generally accepted theory of the pathogenesis of gastroschisis. Most likely is the rupture of physiological hernia along the umbilical cord in its pars flaccid, with the subsequent elongation of the midgut out of the abdominal cavity with the vascular compression, especially of venous and lymphatic vessels. Narrow mesenteric root and narrow-sized defect may contribute to various complications that jeopardize the ultimate prognosis. Further studies are needed to finalize the pathogenesis of gastroschisis. No conflict of interest was declared by the author. Key words: gastroschisis, pathogenesis, vascular disorders, embryonic disorders.

Synchronous rectal prolapse and midgut volvulus presenting as complete small bowel gangrene

<b>Introduction:</b> Adult midgut malrotation is very rare. The presentation in adults is mostly subtle; the diagnosis is often made on imaging. <br><b>Case report:</b> A 32-year-old man presented with a 3-day history of an irreducible painful mass protruding per rectum, followed by abdominal pain and constipation. The patient was febrile and toxic, with marked signs of peritonitis and complete fullthickness irreducible rectal prolapse. Abdominal radiographs showed multiple air-fluid levels. A diagnosis of irreducible rectal prolapse with intestinal obstruction was made. Laparotomy revealed complete small bowel gangrene, abnormal rotation of the small bowel 180° around the mesenteric root, hypermobile duodenojejunal flexure and ileocaecal junction and an abnormally mobile caecum lying in the central abdomen. Abnormal mobility of the sigmoid colon with a large mesocolon, and a large irreducible rectosigmoid intussusception, was also noted. Our patient is probably the first case in literature, which may prompt awareness of simultaneously-occurring disorders of fixation, and preventive steps.

Cutaneous mastocytoma with eosinophilia and eosinophilic infiltration of the small intestine in an Arabian gelding

A 12-year-old Arabian gelding presented to the University of Adelaide for investigation of a firm subcutaneous mass, just proximal to the digital flexor tendon sheath of the right forelimb, that had appeared two weeks prior. The skin overlying the mass was intact. Fine needle aspiration identified eosinophilic and mastocytic infiltrates. One week later, the gelding re-presented for persistent colic signs. Blood examination showed eosinophilia, and on palpation per rectum the mesenteric root was very firm and enlarged and a number of small intestinal loops had subjectively thickened walls. Colic signs were unabated by the administration of pain relief. The owner declined surgery and the gelding was euthanased. Postmortem examination confirmed a diagnosis of cutaneous mastocytoma and revealed eosinophilic infiltration of the small intestine.