Synthol systemic complications: Hypercalcemia and pulmonary granulomatosis. A case report.

INTRODUCTION: Synthol injection for body contouring has been used by bodybuilders for some time. We report two extremely rare systemic complications; pulmonary granulomatosis and hypercalcemia, in a woman who has received Synthol injections for buttocks augmentation. PRESENTATION OF CASE: The case discussed in this report is of a 36-year-old lady who presented for severe hypercalcemia and nephrocalcinosis. Subsequent workup revealed granulomas in the buttocks and in the lungs. Upon questioning, it was discovered that she had received Synthol injection for buttocks augmentation a few months earlier. Labs were consistent with calcitriol mediated hypercalcemia, a phenomenon observed in granulomatous diseases. A diagnosis of foreign body granulomatosis with pulmonary migration and secondary hypercalcemia was made. The patient was started on prednisone and showed an initial positive response. DISCUSSION: Reported complications of Synthol include pain, muscle deformity, and ulceration at the injection site. Hypercalcemia secondary to foreign body granulomatosis after Synthol injection has been reported only once previously, and here we report a second case. The hypercalcemia is thought to be calcitriol mediated, where overexpression of CYP27B1 in the macrophages forming the granulomas leads to pathological extrarenal calcitriol production. Pulmonary granulomatosis, theorized to be secondary to hematologic migration of the injected material, has never been reported previously with Synthol use. CONCLUSION: Synthol injection for body contouring may be a cause of extensive local and pulmonary foreign body granulomatosis leading to calcitriol mediated hypercalcemia. History of cosmetic injections should not be disregarded during history taking.

A non-klatskin tumor: A case report and review of intrabiliary hydatid cyst rupture.

INTRODUCTION: A 64-year-old lady was diagnosed with having a klatskin type 3A tumor based on imaging, however, an alternative diagnosis was achieved during surgery. PRESENTATION OF CASE: We present a case of a 64-year-old lady who presented for new-onset jaundice and was diagnosed with type 3A klatskin tumor based on MRCP findings. During surgery, it was revealed that the obstruction was caused by a frank intrabiliary hydatid cyst perforation. Choledocoscopy with irrigation, cholangiography, and removal of the mother cyst were performed, and an end-to-end biliary anastomosis over a t-tube was then done. The patient tolerated the intervention and recovered well. DISCUSSION: Hydatid cyst disease of the liver usually follows a benign course, however, intrabiliary rupture is one of the common complications associated with this disease. Intrabiliary rupture is classified into either frank or occult. Frank perforation, which is more common, is when hydatid material passes into the biliary ducts, and it may cause biliary obstruction and cholangitis with a high mortality rate. Occult perforation is when the hydatid cyst becomes infected itself, which usually leads to a silent presentation, and may only cause signs of suppuration. Diagnosis is usually achieved by imaging and relevant history. Treatment consists of medical and surgical intervention. Intraoperative cholangiography, choledocoscopy, and t-tube drainage are recommended during surgery for frank rupture. CONCLUSION: Intrabiliary hydatid cyst perforation can mimic cholangiocarcinoma and must be considered as an alternative diagnosis in these patients prior to surgery.

Splenoptosis in young female, case report.

BACKGROUND: Splenoptosis is an uncommon disorder defined as the dislodgment of the spleen from its anatomical location in the left hypochondrium to another location in the intraabdominal cavity. This migration is the result of laxity or absence of the ligaments that fix the spleen to surrounding structures. Splenoptosis is either diagnosed after it causes symptoms, or incidentally using different imaging modalities. Surgery is the definite treatment either by splenopexy or splenectomy. CASE PRESENTATION: In the case presented here, we discuss a 17 years old female patient who presented to our institution for acute onset of abdominal pain, mainly suprapubic, occurring for 4 days. Ultrasound showed a suspicious right pelvic mass, which was found to be a wandering spleen with pedicle torsion. The patient was treated surgically by splenectomy. CONCLUSION: We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of unspecific abdominal pain.

Recurrent giant retroperitoneal liposarcoma with 10 years follow up. Case report and review of literature.

INTRODUCTION: This case is of a patient with a recurrent giant retroperitoneal liposarcoma, followed-up and operated multiple times over 10 years. We report this case because of its rarity and review all previous articles reporting "Giant Retroperitoneal Liposarcoma" in the English literature. CASE DESCRIPTION: A 70 years old man presented to our clinic for dizziness and fatigue. He was incidentally found to have a large retroperitoneal mass filling all the length of the abdominal cavity and shifting all intraabdominal viscera and kidney to the left side. En bloc excision of a 50 × 30 × 18 cm, 9 kg tumor was performed. Final pathology revealed a well-differentiated liposarcoma. Five years later, the patient was reoperated for recurrence and a well-differentiated liposarcoma was excised in 2 pieces (the biggest measuring 14 × 11 × 7 cm) along with the appendix. Four years later the patient was operated on again for a second recurrence, and again a well-differentiated liposarcoma (16 × 10 × 7 cm) extending into the right inguinal canal was excised. One year thereafter, the patient was diagnosed with a third recurrence (22 × 12 cm). DISCUSSION: Retroperitoneal Liposarcomas are rare tumors, presenting with different histological differentiation. They are diagnosed using multiple imaging modality, mainly CT scan, and it is confirmed by percutaneous large core needle biopsy. R0 Surgical excision remains the proper treatment for non-metastatic tumors, which may necessicate multiorgan resection. They rarely grow to reach a large size and be labled as "Giant Retroperitoneal Liposarcoma".

A caustic ingestion consequence mistaken for gastric cancer: A case report.

INTRODUCTION: This report is a case of a suicide attempt by bleach ingestion. mistaken for gastric cancer after oral contrast studies and esophagogastroduodenoscopy. We report this case to encourage physicians to take this etiology into consideration as part of differential diagnosis especially in front of a secretive patient. PRESENTATION OF CASE: We report a case of a 38-year-old lady admitted for an acute onset of symptoms leading to a diagnosis of antral stenosis. Further workup which included endoscopic and surgical biopsies failed to reveal an underlying malignancy. After 24 days of inconclusive inpatient investigations, and due to failure of conservative treatment, distal gastrectomy was performed. Final pathology also revealed an absence of any signs of malignancy, and reported only inflammatory changes. One month after discharge, the patient confessed that she had attempted suicide by ingestion of corrosive agents before the symptoms started and wanted to keep the incident as a secret. DISCUSSION: Gastric stenosis is seldom encountered in adult patients, however, it can occasionally result secondary to gastric ulcer disease, malignancies, foreign body ingestion, certain drugs or chemicals, or after endoscopic or surgical interventions. These etiologies do not usually cause acute gastric obstruction, and usually follow a more indolent course. Identification of an underlying etiology is mandatory to determine the proper medical or surgical treatment to relieve the obstructive symptoms. CONCLUSION: We report this bizarre case to encourage physicians to keep this etiology in mind in otherwise unexplained gastric stenosis.

Rare presentation of community acquired pneumonia resulted in laparoscopic intervention in adult. Case Report.

INTRODUCTION: Community acquired pneumonia usually presents with typical clinical and radiological signs allowing for a quick diagnosis. Nevertheless, pneumonia can infrequently mimic acute abdominal pathologies, leading to invasive unnecessary procedures. PRESENTATION OF CASE: We report a case of a 44-year-old man, previously healthy, admitted with a diagnosis of a surgical abdomen, investigated with an exploratory laparoscopy after inconclusive imaging and failure of improvement. Clinical evolution revealed the diagnosis of pneumonia. DISCUSSION: Community acquired pneumonia is a frequently encountered condition. While its clinical presentation is usually related to the respiratory system, extrapulmonary manifestations, including abdominal pain in the pediatric population, are well documented. However, solely severe acute abdominal pain, being as the major presentation, without respiratory symptoms or radiological signs is very rarely reported. CONCLUSION: Community acquired pneumonia can sometimes be a challenging diagnosis. Acute abdominal pain mimicking a surgical abdomen is an infrequent presentation but can confuse physicians when no radiological or clinical signs of pneumonia are present.

Adult patient living 32 years with postduodenal remnant small bowel of only 35 cm in jejunocolic anastomosis type II weaned off parenteral nutrition. A case report.

INTRODUCTION: The small bowel is an essential organ for maintaining adequate nutrition. Decrease in length could be associated with malnutrition and may require that the patient receives parenteral nutritional support. We report a case of a 59-year-old man who survived32 years with a short bowel of 35 cm length without any parenteral nutrition. CASE PRESENTATION: A 59-year-old gentleman, with a history of hypercoagulable state, presented for severe abdominal pain and obstipation of one day's duration. Upon presentation, the patient was hemodynamically unstable, with abdominal guarding and tenderness upon physical examination. Laboratory studies showed metabolic acidosis with leukocytosis and electrolyte disturbances, and an abdominal CT scan showed thickening of the sigmoid and multiple air-fluid levels. The patient was operated urgently for suspicion of mesenteric ischemia, however, he was found intraoperatively to have a very short dilated small bowel with jejunotransverse anastomosis. DISCUSSION: The necessity for surgical resection of the small bowel can arise for a sum of reasons. However, the removal of a big amount of small bowel may not be adaptive and appropriate digestion will no more be possible. In the aftermath of the resection, patients require parenteral nutrition for a certain period after which they may switch to enteral and oral nutrition, and subsequently intestinal adaptation by thickening and growth of the remaining intestinal villi. CONCLUSION: Patients with a short bowel, particularly those surgically removed, can survive even with a very short remaining bowel length, as a result of intestinal adaptation, nutrition enhancement, and elimination of parenteral nutrition.

Primary splenic hydatid cyst treated with laparoscopic spleen preserving surgery: A case report.

BACKGROUND: Primary splenic hydatidosis is an uncommon etiology. Total splenectomy has been the treatment of choice, however, spleen preserving surgery has been gaining popularity. CASE REPORT: We present a case of a 52-year-old man who was evaluated for a splenic cyst, found incidentally on CT scan done at another institution. MRI was repeated in our institution along with an indirect hemagglutination test to confirm the diagnosis. Since our patient had a single non-complicated cyst confined to the spleen's lower pole, we decided to opt for laparoscopic cyst unroofing and omentoplasty, a spleen preserving technique. DISCUSSION: Due to the rarity of splenic hydatidosis, no strict management guidelines are available, and the decision is usually left for the surgeon. Total splenectomy has been considered the standard of care, however, spleen preserving surgical techniques and percutaneous interventions have been suggested as better alternatives. Spleen preserving techniques lead to surgical outcomes comparable to total splenectomy, with the added benefit of preserving the immunological protection provided by the spleen and protecting patients from dramatic complications that might follow total splenectomy, such as overwhelming post-splenectomy infections, which are associated with very high mortality. CONCLUSION: Laparoscopic cyst unroofing and omentoplasty is a feasible surgical technique to treat primary splenic hydatidosis while preserving the spleen's immunologic function.

Perforated sigmoid colon cancer presenting as an incarcerated inguinal hernia: A case report.

BACKGROUND: Inguinal hernias are common among the population and usually contain part of the omentum or small bowel, however, other unusual contents have been reported. We report a case of a patient who presented for an incarcerated left inguinal hernia and was found to have an underlying perforated sigmoid cancer. SUMMARY: An 87 years old man presented with typical signs of an incarcerated left inguinal area. During surgery, we dissected free a herniated hard inflammatory mass until it was found to be covering an underlying perforated sigmoid tumor. Inguinal hernia is a common condition affecting many individuals, and colorectal cancer is one of the rare contents reported inside these hernias. Due to the rarity of such a presentation, the surprise encounter during groin surgery may lead to suboptimal treatment. Perforated colorectal cancer, like in our case, may signify a more aggressive disease, and hence a correct diagnosis is crucial to improve outcomes. When underlying colon cancer is suspected during hernia surgeries, proper exploration and oncologic resection might be the optimal choice. CONCLUSION: Surgeons should keep the possibility of underlying colorectal cancer in mind when operating on inguinal hernias and opt for oncologic resection of the identified tumor along with proper lymph node dissection.

Ectopic adrenal gland in an adult inguinal hernial sac: A case report.

INTRODUCTION: A 37-year-old male patient operated for inguinal hernia repair was found to have ectopic adrenocortical tissue in the hernial sac. CASE PRESENTATION: A 37-year-old man was admitted for bilateral inguinal hernia. An uneventful open repair was done, and the resected hernial sacs were sent to pathology. Histopathology reported the presence of adrenocortical tissue in the right inguinal hernial sac. DISCUSSION: Ectopic adrenocortical tissue (EACT) in the groin region is not an unusual finding in children, however, it's rarely reported in adult patients. Only 9 cases have been reported in English describing EACT in an adult's inguinal hernia. The finding can be attributed to the close proximity of the developing gonads and adrenal cortex during embryogenesis, and subsequent mechanical translocation of adrenocortical tissue during testicular descent. Some theoretical clinical implications exist for this condition, including secondary hyperplasia after adrenalectomy, adrenal insufficiency in certain situations, and possible neoplastic transformation. Generally, it is recommended that surgeons resect ectopic adrenal glands when identified intra-operatively. However, actively searching for these glands has no known benefit and carries some surgical risks, and is hence not recommended. It is reasonable as well, that clinicians keep the clinical implications of this finding in mind during future follow-ups with such patients. CONCLUSION: The presence of ectopic adrenocortical tissue in inguinal hernia sacs is a rare encounter in adults. The condition can have several theoretical clinical implications that need to be considered by surgeons while assessing patients in whom this phenomenon is observed.

A giant mesenteric fibromatosis adherent to the appendix and colonic wall, case report.

BACKGROUND: Mesenteric fibromatosis, is a rare neoplasm arising usually from the bowel mesentery, with intermediate behavior and local invasion potential. They can be sporadic or related to multiple factors contributions. They usually presents as an asymptomatic growth of intraabdominal mass, and can reach a large diameter before symptoms appearance. Surgical excision is the definitive treatment when achievable. CASE PRESENTATION: In this case we present a case of 34 years old gentleman, presenting for painless abdominal distension, and found to have a giant mesenteric fibromatosis of 23 cm diameter and 4.5 kg arising from the appendix and colonic mesentery. Treated surgically, and was free of recurrence after 1 year follow up. CONCLUSION: We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of unspecific abdominal mass.