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Cureus Aug 2022Sclerosing mesenteritis (SM) is a rare inflammatory fibrotic disease of the small intestine mesenteric fat often discovered incidentally on a CT scan. Clinical...
Sclerosing mesenteritis (SM) is a rare inflammatory fibrotic disease of the small intestine mesenteric fat often discovered incidentally on a CT scan. Clinical manifestations depend on the mass effect on the viscera and vessels. The most common symptoms are abdominal pain, bloating, and nausea. SM occurs predominantly in Caucasian men, during the fifth to seventh decades of life. We present a 69-year-old woman with SM whose symptoms were thought to be from irritable bowel syndrome. A 69-year-old female with a history of fibromyalgia presented with recurrent bouts of abdominal pain across her mid-abdomen lasting 30 minutes to an hour associated with nausea, alternating constipation and diarrhea with occasional mucus, and bloating. She used bismuth subsalicylate and ondansetron with temporary relief. Upper endoscopy and colonoscopy were unrevealing. Initially, she was felt to have irritable bowel. Later she presented with nausea and right upper quadrant pain and underwent cholecystectomy. When her pain recurred, the patient had a CT abdomen and pelvis which showed multiple sub-centimeter mesenteric lymph nodes with surrounding haziness and stranding in the root of the mesentery consistent with SM. The patient had a pannus biopsy showing fat necrosis that confirmed the diagnosis. She continued to have waxing and waning symptoms over several years and in the interim was diagnosed with melanoma limited to the skin. The patient had a particularly severe episode of abdominal pain prompting a repeat CT scan with a subsequent biopsy of an enlarged left para-aortic lymph node that revealed lymphoma. Our patient's diagnosis of SM was delayed as her symptoms were mistaken for irritable bowel syndrome. Worsening symptoms should alert clinicians to an alternate diagnosis such as SM. There are characteristic radiographic findings on CT scans and biopsy of the lesions. SM's association with neoplastic diseases such as lymphoma, melanoma, colorectal, and prostate cancer is controversial, however, practitioners should be aware of this possibility and consider biopsy for any suspicious lesions.
PubMed: 36185930
DOI: 10.7759/cureus.28573 -
Journal of Medicine and Life Jun 2022Elements that comprise the inferior hypogastric plexus are difficult to expose, intricate, and highly variable and can easily be damaged during local surgical...
Elements that comprise the inferior hypogastric plexus are difficult to expose, intricate, and highly variable and can easily be damaged during local surgical procedures. We aimed to highlight, through dissection, the origin, formation, and distribution of the hypogastric nervous structures and follow them in the female pelvis. We performed detailed dissections on 7 female formalin-fixed cadavers, focusing on structures surrounding the pelvic organs. For each hemipelvis, we removed the peritoneum from the pelvic floor, and after we identified the hypogastric nerves, we continued our dissection towards the inferior hypogastric plexuses, following the branches of the latter. Laterorectally, the hypogastric nerves form the inferior hypogastric plexus, a variable structure - nervous lamina, neuronal network (more frequently), or sometimes a combination of them. We identified three components of the inferior hypogastric plexus. The anterior bundle travels towards the base of the urinary bladder, the middle part innervates the uterus and the vagina, and the posterior segment provides the innervation of the rectum. The plexus can be identified after removing the pelvic peritoneum and the subperitoneal adipose tissue. Intraoperatively, the structures can be preserved by using an immediately-subperitoneal dissection plane. The variable branches are relatively well-organized around the pelvic vessels, supplying the urinary bladder, the genital organs, and the rectum. The ureter is surrounded by some branches, especially in its last segment, and it also receives innervation directly from the hypogastric nerve. Close to the viscera, the nerves enter neurovascular plexuses, making the intraoperative separation of the nerves and the vessels virtually impossible.
Topics: Female; Humans; Hypogastric Plexus; Pelvis; Peritoneum; Uterus; Vagina
PubMed: 35928357
DOI: 10.25122/jml-2022-0145 -
The American Journal of Tropical... Jul 2022Cystic echinococcosis (CE) of the bone is a rare disease compared with CE of the viscera, and the most involved bony structures are the spine and the pelvis. Both the...
Cystic echinococcosis (CE) of the bone is a rare disease compared with CE of the viscera, and the most involved bony structures are the spine and the pelvis. Both the diagnosis and the treatment of bone CE are challenging for several reasons. The combination of surgery and antimicrobial therapy is the most common approach, the results are far from adequate. Luckily, percutaneous treatment has appeared on the horizon for bone lesions as a more practical option with fewer drawbacks in light of current reports. This article deals with the successful result of ablation-assisted percutaneous treatment of a bone CE lesion and a soft tissue CE lesion treated by modified catheterization technique in a male patient with left hip pain that was unresponsive to previous surgery for CE.
PubMed: 35895346
DOI: 10.4269/ajtmh.22-0066 -
International Urogynecology Journal Feb 2023Pelvic organ prolapse (POP) is often diagnosed during an in-office examination, which looks for motion of the vaginal wall while performing a strain maneuver. It is...
INTRODUCTION AND HYPOTHESIS
Pelvic organ prolapse (POP) is often diagnosed during an in-office examination, which looks for motion of the vaginal wall while performing a strain maneuver. It is believed that the pelvic organs in adequately supported women are relatively stationary. This study was aimed at investigating the physiological displacements of pelvic organs using MR defecography.
METHODS
This prospective cohort study included 19 volunteers. Midsagittal slices representing rest and the maximum movement of the posterior vaginal fornix during three maneuvers were identified. Normalized axes for analysis were defined as the x' (line connecting the inferior-posterior-most point on the pubic symphysis to the anterior edge of the sacrococcygeal joint) and the y' (line orthogonal to the x axis that passed through the sacral promontory). The positions of the posterior vaginal fornix, mid-vagina, bladder neck, anorectal junction, and hymen were recorded. These subjects were then analyzed using the current radiological grading system of POP to determine any overlap between asymptomatic subjects and diagnostic ranges of POP.
RESULTS
Evacuation caused the most motion in the landmarks. The majority of the motion of the landmarks was along the y axis. The posterior vaginal fornix experienced significant descent (125% of the initial distance) without much anterior-posterior translation (7% of the initial distance) during defecation. All landmarks experienced similar trends.
CONCLUSIONS
We have shown that there is significant rotational motion of the pelvic organs around the pubic bone in adequately supported women. This motion when described using radiological grading is likely to be considered mild or moderate prolapse, which may contribute to overdiagnosis of POP.
Topics: Female; Humans; Viscera; Prospective Studies; Pelvic Organ Prolapse; Vagina; Pelvic Floor
PubMed: 35794274
DOI: 10.1007/s00192-022-05282-7 -
BMC Women's Health Jun 2022Primary clear cell adenocarcinoma of the urethra is extremely rare, reported only in single case reports, and its histological origin is not clear. There is no standard... (Review)
Review
BACKGROUND
Primary clear cell adenocarcinoma of the urethra is extremely rare, reported only in single case reports, and its histological origin is not clear. There is no standard treatment for CCAU at present, and surgery is still the main treatment for CCAU without distant metastasis.
CASE PRESENTATION
A 67-year-old female complained of gross hematuria with frequent micturition and urgency. No urethral diverticulum was found by cystoscopy or MRI, and the mass grew around the urethra. Urethral and anterior pelvic viscera resection was performed. Clear cell adenocarcinoma was confirmed by immunohistochemistry after the operation, and no recurrence or metastasis was found after one year of follow-up.
CONCLUSION
CCAU is very rare, and most cases originate from the urethral diverticulum and some may also originate from tissues around the urethra. For CCAU patients without distant metastasis, the main treatment is still surgery, and radiotherapy and chemotherapy can be performed for patients with distant metastasis. Gene detection may provide guidance for the precise chemotherapy of CCAU.
Topics: Adenocarcinoma, Clear Cell; Aged; Diverticulum; Female; Humans; Magnetic Resonance Imaging; Urethral Neoplasms; Urinary Tract
PubMed: 35751118
DOI: 10.1186/s12905-022-01835-6 -
International Journal of Surgery Case... Jul 2022Aggressive Angiomyxoma (AA) is an uncommon, locally infiltrative mesenchymal tumor that primarily originates from perineal and pelvic sites of women, particularly in the...
INTRODUCTION AND IMPORTANCE
Aggressive Angiomyxoma (AA) is an uncommon, locally infiltrative mesenchymal tumor that primarily originates from perineal and pelvic sites of women, particularly in the 4th decade of life with having an emphasized tendency for local recurrence, whereas it has a low tendency to metastasize. Patients often present with nonspecific symptoms such as painless visible mass that might be misdiagnosed with every mass in genital and pelvic sites in reproductive-age women.
CASE PRESENTATION
We describe a 31-year-old female presenting with an enlargement on the right labia majora. Ultrasound and magnetic resonance were carried out, and the mass was surgically excised completely and without complication. The diagnosis of AA was made based on characteristic histopathological features. The postoperative follow-up for recurrence is currently being continued.
CLINICAL DISCUSSION
Due to its rarity and lack of specificity in clinical and radiological examinations, the pre-operative misdiagnosis rate of AA is rather high. Hence, most cases are diagnosed on histology after initial surgical excision. Surgical management is the gold standard treatment for primary tumors; however, in case of local recurrences, treatment choices range from surgical resection to gonadotropin-releasing hormone (GnRH) agonist for tumors positive for estrogen and progesterone receptors.
CONCLUSION
Wide surgical resection is the gold standard treatment of AA; however, exceptions might occur due to the depth of tumor infiltration to adjacent viscera. Therefore, adjunct medical therapies can play a crucial role in treatment. In addition, long-term follow-up is necessary due to the high rate of local recurrences.
PubMed: 35716621
DOI: 10.1016/j.ijscr.2022.107313 -
International Journal of Surgery Case... May 2022Internal hernias are a rare phenomenon, and even rarer is a herniation through the foramen of Winslow. The clinical presentation of patients with an internal hernia is...
INTRODUCTION
Internal hernias are a rare phenomenon, and even rarer is a herniation through the foramen of Winslow. The clinical presentation of patients with an internal hernia is often vague and difficult to diagnose clinically. If internal hernias go undiagnosed and untreated, patients can develop bowel compromise leading to a high morbidity and potential mortality. Radiologic imaging is helpful in bringing the diagnosis to the forefront of the clinicians mind, but the diagnosis is often made intra-operatively.
PRESENTATION OF CASE
An eighty-one year old female presenting with a few months of vague abdominal symptoms who was found to have a cecal bascule internally herniating through the foramen of Winslow was treated successfully with surgical intervention.
DISCUSSION
Internal hernias occur when there is a protrusion of a viscera through the peritoneum or mesentery and confined within the abdominal cavity. Internal hernias are classified according to location and vary from paraduodenal, transmesenteric, and pelvic to name a few. Hernias through the foramen of Winslow are a rare subset, and were the internal hernia found in our patient intra-operatively. Our patient's clinical presentation was vague with generic abdominal complaints and radiologic imaging was inconclusive for a definitive diagnosis. However, prompt surgical intervention resulted in a good outcome for our patient.
CONCLUSION
Internal hernias, to be diagnosed and treated promptly, require a high index of suspicion from a clinician based on clinical presentation and radiologic imaging. These patients belong in the operating room, and interventions are directed based on the anatomical findings intra-operatively.
PubMed: 35658294
DOI: 10.1016/j.ijscr.2022.107123 -
Frontiers in Surgery 2022Vaginal evisceration is an extremely rare surgical emergency that can be described as the extrusion of abdominal viscera through a defect or a rupture of the vaginal...
INTRODUCTION
Vaginal evisceration is an extremely rare surgical emergency that can be described as the extrusion of abdominal viscera through a defect or a rupture of the vaginal wall. We reported the case of an acute abdomen due to small bowel evisceration secondary to vaginal vault dehiscence that required combined vaginal-abdominal approach.
CASE
We discuss the case of a 72-year-old female who presented to the emergency department for a large prolapse with visible extrusion of the small bowel per vagina. The eviscerated bowel was resected by external vaginal approach due to excessive swelling of the loops which made it impossible to reduce them through the vagina defect. A midline laparotomy was undertaken for further assessment, and the vault defect was closed by transabdominal repair.
CONCLUSION
From its first description in 1864, just a few cases of vaginal evisceration had been described in the medical literature; the most common organ to eviscerate is the distal ileum, although cases of omentum, colon, fallopian tube, and appendix evisceration have also been reported. We described a rare case of transvaginal evisceration of the small bowel in our emergency department; it is a rare surgical emergency that must be managed to prevent serious consequences, such as bowel ischemia and necrosis, sepsis, and death. We suggest that a multidisciplinary approach to prompt examination and management by gynecologists and general surgeons is recommended to reduce the risk of morbidity and mortality. With this paper the authors would like to share the surgical manage of this rare emergency with other surgeons all around the world.
PubMed: 35558386
DOI: 10.3389/fsurg.2022.878760