Diagnosing and managing small bowel neuroendocrine tumors presenting as acute obstruction in an elderly patient: A case report and comprehensive management overview.

INTRODUCTION AND IMPORTANCE: Neuroendocrine tumors (NETs) of the small bowel are rare but clinically significant due to their challenging diagnostic pathways and potential for insidious progression. Early identification is critical for effective management and improved prognosis in these cases. CLINICAL PRESENTATION: Here, we present a case of a 75-year-old patient with no significant medical history who presented acutely with diffuse abdominal pain, vomiting, and signs of bowel obstruction. Diagnostic workup, including CT imaging, revealed a distal ileal neuroendocrine mass with mesenteric lymphadenopathy, necessitating urgent surgical intervention. DISCUSSION: This case underscores the diagnostic complexities and therapeutic challenges associated with small bowel NETs. Surgical resection with meticulous lymph node dissection remains the cornerstone of treatment, aimed at achieving complete tumor excision and optimal disease control. The role of imaging modalities and biochemical markers in guiding clinical decisions and postoperative management strategies is discussed considering the patient's clinical course. CONCLUSION: Timely recognition and intervention are crucial in the management of small bowel NETs, given their potential for late presentation and nonspecific symptoms. Despite diagnostic and procedural challenges highlighted in this case, early surgical intervention and comprehensive follow-up are essential for achieving favorable outcomes and minimizing recurrence risks in patients with small bowel NETs.

Anaphylaxis triggered by a hidden threat: A rare hydatid disease case report.

INTRODUCTION AND IMPORTANCE: Hydatid disease, caused by Echinococcus granulosus, is a zoonotic infection prevalent in specific regions, including Tunisia. Complications are rare but potentially life-threatening. This case report highlights the significance of early diagnosis and intervention in a unique case where anaphylaxis resulted from minor abdominal trauma in a 17-year-old male with an undiagnosed hydatid cyst. CASE REPORT: The patient arrived at the emergency department with syncope and hypotension after a classroom accident. Physical examination showed an urticarial rash and abdominal tenderness. Anaphylactic shock was diagnosed and promptly treated. A computed tomography scan confirmed a ruptured liver hydatid cyst. The patient received anthelmintic treatment and underwent conservative surgical management. Intraoperatively, a second anaphylactic shock occurred and was promptly treated. The post-operative course was uneventful, and histopathological analysis identified Echinococcus granulosus. CLINICAL DISCUSSION: This case emphasizes the importance of recognizing hydatid disease as a potential cause of anaphylaxis post-trauma, even in asymptomatic patients. Early diagnosis through imaging is crucial for prompt intervention. Surgical management should be considered, with conservative approaches favored in acute cases. Post-surgical albendazole treatment is essential to prevent recurrence. CONCLUSION: This report serves as a valuable reference for healthcare professionals, highlighting the need for heightened clinical suspicion in cases like this. It underscores the significance of considering hydatid cyst rupture in the differential diagnosis of anaphylaxis following blunt trauma. Awareness among pediatricians, emergency physicians, and primary care providers can lead to early diagnosis and better patient outcomes, preventing severe complications or fatalities associated with this rare condition.

Doubly complicated: A case of massive non-parasitic liver cyst presenting with dyspnea and inferior vena cava compression: A rare case report.

INTRODUCTION AND IMPORTANCE: Simple hepatic cysts, common benign liver conditions, are increasingly detected incidentally due to advancements in imaging technologies. While typically asymptomatic, complications such as compression of neighboring structures can arise, presenting unique diagnostic and management challenges. We present a doubly complicated case of a massive non-parasitic liver cyst in a 61-year-old female patient, manifesting with dyspnea and compression of the inferior vena cava. CASE PRESENTATION: A 61-year-old female with a history of treated hypertension presented with worsening dyspnea over six months. Physical examination revealed a large, painless abdominal mass, and imaging confirmed a 20 cm cystic liver mass compressing the inferior vena cava and exerting a mass effect on the diaphragm. Surgical exploration and deroofing of the cyst led to successful resolution. CLINICAL DISCUSSION: The presentation of dyspnea in non-parasitic liver cysts is rare but notable, highlighting the importance of considering hepatic etiologies in respiratory symptoms. Imaging modalities such as ultrasound and CT play crucial roles in diagnosis, while MRI aids in ruling out biliary-cystic fistulas. Surgical management, particularly subcostal laparotomy, remains a viable option for complex cases. CONCLUSION: This case underscores the need for heightened awareness of atypical presentations of non-parasitic liver cysts and the significance of imaging in diagnosis. Subcostal laparotomy, though associated with limitations, remains valuable in select cases. Further research comparing surgical approaches is warranted to optimize management strategies for symptomatic non-parasitic liver cysts.

A case report: Peritonitis secondary to perforated locally advanced gastrointestinal stromal tumor.

INTRODUCTION AND IMPORTANCE: Gastrointestinal stromal tumors (GISTs) are rare mesenchymal neoplasms predominantly affecting the gastrointestinal tract. While they often remain asymptomatic, GISTs can lead to acute abdominal emergencies, such as peritonitis secondary to tumor perforation, a rare yet serious complication. Here, we present a unique case of a locally advanced ileal gastrointestinal stromal tumor complicated by generalized purulent peritonitis, emphasizing the diagnostic and management challenges associated with this condition. CASE PRESENTATION: A 68-year-old male presented with worsening abdominal pain, vomiting, fever, and weight loss. Imaging studies revealed a large solid-cystic mass originating from the terminal ileum, prompting emergency surgery. Intraoperative findings included a multilobulated tumor mass invading the mesocolon, necessitating hemicolectomy. Histopathological analysis confirmed a high-risk gastrointestinal stromal tumor, leading to initiation of adjuvant therapy with imatinib mesylate. CLINICAL DISCUSSION: GISTs often present with nonspecific symptoms, posing diagnostic challenges. Peritonitis secondary to tumor perforation is a rare yet critical complication requiring prompt surgical intervention. Complete resection remains the mainstay of treatment, with adjuvant imatinib therapy showing promise in high-risk cases. CONCLUSION: This case report sheds light on the complexities of diagnosing and managing locally advanced gastrointestinal stromal tumors (GISTs) complicated by peritonitis. Complete tumor resection is crucial for potential cure, with adjuvant therapy using imatinib showing promise, especially in high-risk cases. Thorough diagnostic assessment, timely intervention, and comprehensive follow-up are essential for optimizing outcomes in complex GIST presentations.

Diagnostic and therapeutic challenges in isolated perianal tuberculosis: A case report and comprehensive management overview.

INTRODUCTION AND IMPORTANCE: Tuberculosis (TB) remains a significant global health concern, particularly in low-income countries like Tunisia, despite advancements in healthcare and antibiotic accessibility. Gastrointestinal tuberculosis, although rare, can affect various parts of the gastrointestinal tract, with perianal involvement being exceptionally uncommon. We present a case of isolated perianal tuberculosis, emphasizing the complexities in diagnosis and management. In this context, we present a case of isolated perianal tuberculosis in a 51-year-old male, highlighting the diagnostic challenges and emphasizing the need for early recognition and comprehensive management strategies. CASE PRESENTATION: A 51-year-old male presented with recurrent anal pain and purulent perianal discharge, without respiratory or gastrointestinal symptoms. Physical examination revealed indurated ulceration and fistulas, suggestive of recurrent anal fistulas. Biopsy and culture confirmed the diagnosis of isolated perianal tuberculosis, with no pulmonary or gastrointestinal involvement. CLINICAL DISCUSSION: Perianal tuberculosis presents unique challenges in diagnosis and management, often mimicking other conditions like Crohn's disease. Differential diagnosis requires a multidisciplinary approach, including biopsy, acid-fast staining, polymerase chain reaction, and cultures. Successful management involves a combination of surgical intervention and antituberculous therapy, yielding favorable outcomes with minimal recurrence. CONCLUSION: Early recognition and comprehensive management are crucial in isolated perianal tuberculosis to prevent recurrence and unnecessary surgical interventions. This case underscores the importance of considering tuberculosis in the differential diagnosis of perianal pathologies, particularly in TB-endemic regions like Tunisia. Prompt initiation of appropriate therapy is essential for favorable patient outcomes.

Total small bowel volvulus on incomplete common mesentery, an exceptional complication in geriatric patients: A rare case report.

INTRODUCTION AND IMPORTANCE: The incomplete common mesentery, resulting from a rotational anomaly, is a rare but potentially life-threatening condition. This congenital anomaly is characterized by persistent embryonic bowel arrangement and an extremely short mesentery root. Complications typically manifest during neonatal or pediatric stages, with limited occurrences in adulthood. Herein, a compelling case of an 83-year-old male with small bowel volvulus and incomplete common mesentery, underscoring the critical importance of recognizing and addressing rare but potentially life-threatening complications in the geriatric population. CASE PRESENTATION: An 83-year-old male, post-prostatectomy, presented with acute abdominal distress, indicating small bowel volvulus associated with incomplete common mesentery. Dehydration signs were evident on admission, and imaging confirmed the diagnosis. Urgent surgical intervention, including the Ladd procedure, successfully resolved the condition with a six-day recovery. CLINICAL DISCUSSION: Fetal digestive tract rotation anomalies lead to incomplete common mesentery, posing risks of volvulus. Complications, whether acute or chronic, require timely recognition. Diagnostic modalities, including the "whirlpool" sign on imaging, play a vital role. The Ladd procedure remains the standard treatment, addressing mesenteric anomalies and preventing recurrence. CONCLUSION: This case highlights the critical nature of small bowel volvulus with incomplete common mesentery, emphasizing the importance of recognizing and managing this rare condition promptly. Awareness, diagnostic accuracy, and timely surgical intervention are crucial for favorable outcomes, particularly in the geriatric population.

Diagnostic consideration of lipoma-like lesion: A case report of primary cutaneous Rosai-Dorfman disease.

INTRODUCTION AND IMPORTANCE: Rosai-Dorfman disease (RDD) is a rare disorder characterized by benign histiocytic proliferation. The purely cutaneous variant of Rosai-Dorfman disease is exceptionally uncommon. This abstract centers on an extraordinary case-an instance of primary cutaneous Rosai-Dorfman disease (PCRDD), a rare cutaneous variant within an already infrequent disorder. Successfully managed through surgical intervention, this unique case underscores the pressing need for refined diagnostic and therapeutic strategies. CASE REPORT: We present a noteworthy case of primary cutaneous Rosai-Dorfman disease (PCRDD) in a north African female, deviating from the typical age of onset. The patient exhibited a rare cutaneous variant, emphasizing the need for heightened awareness in diverse demographics. Histological analysis revealed characteristic emperipolesis and immunohistochemical features consistent with RDD. CLINICAL DISCUSSION: PCRDD, although uncommon within the Rosai-Dorfman Disease spectrum, manifests with a later onset and distinctive demographic characteristics. Surgical excision emerges as a viable therapeutic option for managing symptomatic lesions, as demonstrated in our case. The infrequency of PCRDD underscores the importance of tailored diagnostic and therapeutic strategies. Individualized approaches become pivotal in addressing the complexities associated with PCRDD, ensuring careful consideration of its intricacies in the broader context of Rosai-Dorfman disease. CONCLUSION: This case underscores the complexity of RDD, especially in rare cutaneous presentations. Surgical excision, with its reported efficacy, stands as a crucial intervention, offering both symptomatic relief and potential cure, showcasing the significance of individualized care in managing this rare disorder. Continued research remains imperative for advancing RDD understanding and refining clinical approaches.

Surgical perspective on perianal Bowen's disease: A rare case report.

INTRODUCTION AND IMPORTANCE: Bowen's Disease (BD) stands out as a dermatologic entity known for its rarity and diagnostic intricacies. While BD is recognized for its diverse clinical presentations, its occurrence in the perianal region is particularly exceptional. Our case contributes to the limited body of knowledge regarding perianal BD, shedding light on its distinctive characteristics and guiding clinicians in navigating the intricacies associated with this uncommon presentation. CASE PRESENTATION: We present the case of a 67-year-old female who sought medical attention for persistent itching in the perianal region. A thorough examination revealed a solitary BD lesion, a notable rarity in this anatomical site. Considering the distinctive characteristics and location, surgical excision was chosen as the preferred treatment strategy. The postoperative course was straightforward, yielding favorable aesthetic outcomes and no recurrence. CLINICAL DISCUSSION: The clinical discussion explores the unique challenges associated with perianal BD, emphasizing the rarity of its presentation and its potential to mimic other dermatologic conditions. Factors contributing to the diagnosis, including clinical indicators and risk factors, are scrutinized. Furthermore, the discussion delves into the evolving landscape of diagnostic tools and treatment modalities, especially relevant in the context of perianal BD. CONCLUSION: This case illuminates the rarity of BD in the perianal region, serving as a valuable addition to the limited body of knowledge on this unusual presentation. By unraveling the complexities associated with perianal BD, this report contributes to a deeper understanding of the disease and provides insights that can guide clinicians in navigating similar cases.

A rare case report: Huge ileal leiomyoma: Clinical presentation, management, and implications.

INTRODUCTION AND IMPORTANCE: Leiomyomas, commonly known as fibroids, are benign soft tissue tumors mostly found in the uterus. Although predominantly uterine, they can occur rarely in other areas, notably in the gastrointestinal tract. This article emphasizes an unusual case: an ileal leiomyoma in a 54-year-old patient, showcasing the distinct diagnostic and management challenges it presents. CASE REPORT: A 54-year-old female with no prior medical history presented with a progressively enlarging, painful abdominal mass over six months. Imaging suggested a Gastrointestinal Stromal Tumor (GIST), but guided biopsy yielded an unexpected diagnosis of ileal leiomyoma. Subsequent surgical intervention successfully removed the tumor, leading to an uneventful postoperative recovery. CLINICAL DISCUSSION: This case underscores the diagnostic intricacies and clinical manifestations of ileal leiomyomas. While diagnosis can be challenging, timely histopathological evaluation is crucial. Surgical resection guided by pathological findings played a pivotal role in this patient's care, emphasizing the need for a comprehensive approach to diagnosis and treatment in unique medical cases. CONCLUSION: The rarity of ileal leiomyomas presents a substantial challenge in the medical field, where expertise can be limited. This case emphasizes the pivotal role of histopathological analysis in confirming the diagnosis and guiding effective surgical management.

A rare case report: Gallbladder-associated ectopic liver tissue: Challenges, insights, and surgical considerations.

INTRODUCTION AND IMPORTANCE: Ectopic liver tissue (ELT), a rare anomaly distinct from accessory liver, challenges conventional embryonic morphogenesis. Unlike the latter, ELT lacks a connection to the main liver, showcasing an unusual growth of normal liver tissue beyond its customary location. This peculiarity poses clinical and radiological challenges for surgeons throughout their careers, particularly during laparoscopic or open procedures. Elevated clinical significance arises from ELT's potential to progress into hepatocellular carcinoma, necessitating heightened awareness among surgeons. CASE REPORT: This article presents a compelling case of ELT, discovered incidentally during a planned laparoscopic cholecystectomy. The patient, a 60-year-old female with a history of biliary colic, underwent a meticulous exploration revealing an undistended gallbladder with an unexpected brownish tissue fragment resembling hepatic parenchyma. CLINICAL DISCUSSION: Ectopic liver tissue, dating back to early 20th-century records, challenges precise incidence determination. Theories regarding embryonic development around the fourth week in utero provide insights into ELT's origins and displacement from the hepatic diverticulum. Varied attachment locations and potential manifestations in other intra-abdominal and intra-thoracic sites add layers to the complexity of its diagnosis. Radiological studies, though challenging, offer glimpses of ELT, cautioning against percutaneous biopsies due to associated risks. CONCLUSION: In conclusion, this case of ELT offers valuable insights into its diagnostic challenges and surgical considerations, underscoring the need for continued research and heightened awareness in the medical community. The rarity and varied presentations of ELT warrant ongoing exploration to refine diagnostic approaches and optimize patient outcomes.

A rare case report: Spontaneous rectus sheath and iliopsoas hematomas: Clinical presentation, management, and implications.

INTRODUCTION AND IMPORTANCE: Frequently misdiagnosed, the clinical condition of soft tissue hematoma typically emerges following blunt abdominal trauma and/or anticoagulant medication usage, with spontaneous occurrences being infrequent. In this case report, we present a spontaneous rectus sheath and iliopsoas hematomas without obvious classical risk factors. The purpose of presenting this case is to bring attention to this unusual clinical condition and emphasize the role of thorough history and physical examination in determining the suitable course of treatment. CASE REPORT: A 50-year-old woman with no medical history presented at the emergency room due to sudden asthenia and abdominal pain. Physical examination revealed a painful 20 cm hypogastric mass and left lumbar swelling causing leg bending. Lab tests indicated anemia and normal coagulation. CT scans showed significant hematomas in the left rectus and psoas muscles. Intensive monitoring and supportive measures stabilized her condition without resorting to surgery. CLINICAL DISCUSSION: Soft tissue hematomas, notably in the rectus sheath or iliopsoas muscle, are rare but potentially severe conditions. Their pathophysiology is not fully understood, and risk factors include age, anticoagulant use, and comorbidities. Diagnosis involves abdominal examination, anemia, and CT findings. Management varies based on symptom severity and blood loss, ranging from conservative approaches to surgery or embolization. CONCLUSION: Swift identification and effective handling of soft tissue hematomas hold utmost importance. The thorough history-taking and comprehensive physical examination play pivotal roles within this protocol. While supportive care constitutes the primary mode of management, instances arise where surgical intervention or vascular embolization becomes imperative for hematomas unresponsive to treatment and presenting hemodynamic instability.

Gastrointestinal perforations by ingested foreign bodies: A preoperative diagnostic flowchart-based experience. A case series report.

BACKGROUND: Gastrointestinal tract perforation is the most harmful complication of Foreign Body (FB) ingestion, besides diagnostic delay adversely affects the outcome. This paper aims to present our preoperative diagnostic flowchart and describe the surgical management in a Tunisian center. METHODS: A retrospective review of 48 patients with gastrointestinal perforation by ingested FB treated in the surgery department of Jendouba Hospital. January 2010-December 2020. RESULTS: 48 patients were treated for gastrointestinal tract perforation induced by FB ingestion. The mean age was 56.6 years. The sex ratio was 2/1. Acute abdominal pain was reported in all the patients. 35 patients had abdominal X-ray that showed a FB in 12 cases. CT scan was performed in 38 patients and identified the FB in 28 cases. Postoperative proofreading has identified a preoperative missed diagnosis of FB perforation in 5 cases, all before applying the diagnostic flowchart. All patients underwent open surgery after a median time of 7.12 h. This duration decreased after applying the flowchart (8.21 h versus 5.6 h). 33 patients had a terminal ileum perforation. Enterectomy was performed in 33 patients. Postoperatively, there was one abdominal abscess, one pulmonary embolism, one refractory septic choc, and one wound abscess. The median hospital stay was 6.35 days. The mortality rate was 6.25%. All patients managed with enterostomy had their stoma closed after 3-5 months. CONCLUSIONS: The challenge of gastrointestinal perforation due to FB ingestion is accurate diagnosis and early management. A standardized initial assessment based on a diagnostic flowchart is helpful to achieve this goal and improve outcomes.

Acute intraperitoneal rupture of hydatid cysts of the liver: Case series.

ABSTRACT: Hydatid cyst is a parasitic infection caused mainly by Echinococcus granulosus, which is generally considered benign. However, the hepatic hydatid cyst rupture in the abdominal cavity is a life-threatening incident that requires urgent and multidisciplinary management (emergency physicians, radiologists, anesthetists, and surgeons). This study describes clinical and paraclinical liver hydatid cyst rupture in the peritoneal cavity and details the appropriate treatment.A retrospective review of clinical records of patients hospitalized in Jendouba Hospital for liver hydatid cyst was performed over 8 years, from January 1, 2012 to December 31, 2019. Fifteen cases of liver hydatid cyst complicated with acute rupture into the abdominal cavity were collected out of 625 hydatid liver cysts. All patients underwent emergency laparotomy allowing conservative unroofing procedure associated with peritoneal lavage and external drainage combined with necessary intensive care measures. Clinical features, therapeutic procedures' details as well as postoperative outcomes are reported. Statistical analysis was performed using the Statistical Package for the Social Sciences for Windows version 20.There were 9 men and 6 women. Patients' age ranged from 14 to 59 years, with an average of 38 years. Two patients were admitted with abdominal trauma. Acute abdominal pain was the most common complaint. Only 1 patient had an anaphylactic shock. Abdominal ultrasonography and computed tomography scan showed discontinuous cyst wall associated to intraperitoneal fluid in all cases. Intraoperatively, the intraperitoneal effusion was clear in 13 cases and purulent in 2. All patients underwent unroofing procedures associated with intra-operative peritoneal lavage and external drainage. The mean hospital stay was 6.11 days, and the mean follow-up was 19 months. No case of recurrence was reported among the patients.In endemic areas, rupture of a hepatic hydatid cyst in the abdominal cavity should be considered in every case of acute abdominal pain, especially if associated with anaphylaxis signs. Early management starting in the emergency room is needed to ensure good outcome.

De Garengeot hernia doubly complicated: A case report.

INTRODUCTION: A strangulated De Garengeot's hernia with appendicitis is an extremely rare surgical presentation. Therefore, the diagnosis is challenging, and there are no recommendations regarding a specific surgical approach. PRESENTATION OF CASE: We present the case of a 56-year-old woman with a De Garengeot's hernia doubly complicated: strangulated and with appendicitis in the hernia sac. The diagnosis was made intraoperatively, and it was managed fully through a single inguinal incision. No postoperative complication was presented, and the patient was discharged 48 h after. DISCUSSION: The clinical presentation of this sub-type of hernia is non-specific. Precise knowledge of the hernia sac content preoperatively is not mandatory, and it should not delay prompt emergency surgery. As long as there are no local signs of complicated appendicitis, a single inguinal incision may be sufficient to perform appendectomy and hernia repair. In the event of complicated appendicitis, an exploratory of the abdominal cavity is mandatory, and hybrid approaches are recommended. For an experienced surgeon, the laparoscopic approach (TAPP), including the treatment of the two pathologies and the exploration of the peritoneal cavity, represents the surgical technique of choice. CONCLUSION: De Garengeot's strangulated hernia with appendicitis is an exceedingly rare double surgical emergency. When uncomplicated appendicitis, a single inguinal incision is sufficient to treat both appendicitis and abdominal wall defect. Hernia reduction, which young surgeons in the emergency room commonly attempt, should be abolished.

The deceitful diagnosis of gallbladder volvulus: A case report.

INTRODUCTION AND IMPORTANCE: The gallbladder volvulus is a rare but life-threatening condition characterized by an axial torsion of the gallbladder along the cystic pedicle, causing gallbladder ischemia and necrosis. This paper aims to present and discuss a rare case of gallbladder volvulus. This case report has been reported in line with the SCARE criteria 2020 [1]. CASE PRESENTATION: We report the case of a 90-year-old female patient who presented to the emergency room with sharp right upper abdominal quadrant pain of acute onset associated with vomiting, evolving for the last 12 h. She had no fever nor jaundice. Her body mass index (BMI) was 22. She had kyphosis, and scoliosis. Physical examination found tenderness with a palpable mass in the right upper abdominal quadrant. Laboratory test results showed leukocytosis at 11600 /mL and a high C-reactive protein rate at 40 mg/L revealed acute calculous cholecystitis features. However, emergency laparotomy was performed and discovered a gallbladder volvulus. A detorsion and cholecystectomy were performed with a good outcome. CLINICAL DISCUSSION: The preoperative diagnosis of gallbladder volvulus is difficult due to its misleading clinical presentation mimicking acute cholecystitis. The presence of the three highly suggestive triad clinical signs should encourage the radiologist to search for a gallbladder with a horizontal orientation and located outside its anatomical fossa connected to the liver by a conical structure corresponding to the twisted pedicle in ultrasonography. Unlike ordinary acute cholecystitis, which may sometimes tolerate an initial conservative medical treatment, gallbladder volvulus management is always an emergency cholecystectomy. CONCLUSION: Despite the clinical similarities with the classical acute calculous cholecystitis, gallbladder volvulus is more likely to result in fatal outcome. Therefore, a high level of clinical suspicion is necessary to save lives.