Trichobezoar as a cause of pediatric acute small bowel obstruction.

This case serves to raise awareness of trichobezoar as a diagnosis in young children who present with abdominal pain, a palpable mass, and signs of acute small bowel obstruction.

Systematic review and meta-analysis of the association between diverticulosis of the appendix and neoplasia.

BACKGROUND: Diverticula of the appendix (DA) are infrequent and their clinical implications are often overlooked. Several studies have found a significantly increased prevalence of neoplasms in appendiceal specimens with diverticula. Despite the potential clinical implications, there is a paucity of literature. A systematic review and meta-analysis was performed to evaluate the prevalence of DA and its association with neoplasia. METHODS: A systematic search of literature (Cochrane, EMBASE, PubMed and Medline) reporting the prevalence of DA and association with neoplasia was performed in November 2019. Relevant articles were assessed in accordance with the PRISMA guidelines. Risk of bias assessment was carried out using modified Newcastle-Ottawa scale. Meta-analysis with risk ratio and random-effects model was performed using RevMan. RESULTS: The initial search identified 1122 potential articles of which 11 were appropriate for quantitative analysis. The prevalence rate of DA was 1.74%. The mean age of patients with DA and those without DA was 41.2 and 33.9 years, respectively. The ratio of male to female was 1.8:1. The prevalence of neoplasia in specimens without DA versus those with DA was 1.28% and 26.94%, respectively. Only four studies addressed the prevalence of locoregional neoplasia in the setting of DA compared to control. Meta-analysis with random-effects model demonstrated that pooled risk ratio was 25.46 (95% confidence interval 12.77-50.75, P < 0.00001). CONCLUSION: The strong association with neoplasia in this meta-analysis reinforces the clinical significance of DA. Surgeons, pathologists and radiologists should be mindful of this uncommon pathology and consider individualized patient management, until further evidence can direct clinical guidelines for the management of patients with DA.

Atraumatic splenic rupture after cocaine use and acute Epstein-Barr virus infection: A case report and review of literature.

BACKGROUND: Atraumatic splenic rupture (ASR) accounts for just over 3% of all cases of splenic rupture and is associated with a high mortality rate. The most common culprit is acute infection with Epstein-Barr virus (EBV) but other documented aetiologies include neoplasia, other viral/bacterial infections, acute and chronic pancreatitis, amyloidosis and anticoagulant medications. There are four previous reports of cocaine-associated ASR but never before has it been documented in combination with concurrent acute EBV infection. CASE SUMMARY: A 21-year-old man presented to hospital with acute left shoulder pain which radiated to the right shoulder and upper abdomen. He denied any history of recent trauma and had no relevant past medical history. He took no regular prescription medications but had used cocaine within the previous 24 h. Investigations revealed splenomegaly, a Grade 3 subcapsular splenic haematoma, moderate haemoperitoneum and an incidental 9 mm splenic artery pseudoaneurysm. There was also serological evidence of acute EBV infection. Prophylactic endovascular embolisation of the pseudoaneurysm was performed and the splenic rupture was managed non-operatively. The patient remained admitted in hospital for seven days and did not require any transfusion of blood products. Serial imaging showed complete resolution of the haemoperitoneum after 5 wk. The importance of abstinence from illicit drug use was emphasised to the patient but it is unknown whether or not he remains compliant. CONCLUSION: This case demonstrates that ASR is a rare condition that can result from acute EBV infection and cocaine ingestion and requires a high index of suspicion to diagnose clinically.

Leflunomide-induced colitis in association with enterocutaneous fistula in an immunosuppressed patient with renal transplant and rheumatoid arthritis.

We describe the case of a 68-year-old man who has a complex medical background that included renal transplantation, rheumatoid arthritis and atrial fibrillation. Because of this, he was taking a number of immunosuppressant medications including leflunomide, prednisone and tacrolimus. He had experienced chronic diarrhoea over 18 months which had acutely worsened over the 6 weeks prior to hospital presentation. Recent colonoscopies had been performed to investigate this diarrhoea with biopsies revealing acute and chronic inflammatory changes in the terminal ileum and colon. No infectious cause could be found, with all bacterial and viral stool cultures returning negative. An enterocutaneous fistula had also spontaneously developed through his renal transplant scar in the days preceding hospital admission which complicated the clinical picture. Following dose reduction of leflunomide, there was a significant improvement in the frequency and severity of the patient's diarrhoea. He continues to be managed non-operatively for his fistula as he is at high risk of peri-operative morbidity and mortality.