[Ileal intussusception due to a voluminous inflammatory fibroid polyp. A case report and review of the literature]. / Intussuscezione ileale da voluminoso polipo infiammatorio fibroide. Descrizione di un caso clinico e revisione della letteratura.

An inflammatory fibroid polyp is a rare benign submucosal lesion frequently located in the gastric antrum but it may be found anywhere in the gastrointestinal tract with maximal incidence in the fifth and sixth decades of life. The main histological characteristics are diffuse inflammatory infiltrate with eosinophils, high vascularisation and a myofibroblastic component. Its localisation in the small bowel can cause intestinal invagination in adults, a condition, that occurs most frequently in childhood where, however, it is generally not related to a pathological lesion. The diagnosis may often be delayed because of its non-specific symptoms and most cases are diagnosed at emergency laparotomy, although CT scans can furnish useful preoperative information. In the majority of cases, the treatment of choice is surgical resection. Reduction performed prior to resection proves controversial in patients with colic intussusception because of the high incidence of malignancy. We report a case of a 37-year-old man who had undergone emergency surgery for acute ileum intussusception associated with a voluminous inflammatory fibroid polyp. The case described emphasises that patients with bowel obstruction pose a complex and difficult challenge to surgeons as regards the choice of the correct diagnostic work-up and optimal therapeutic management.

Metastatic melanoma of the small bowel. Report of a case and review of literature.

AIM: Malignant melanoma incidence is rapidly growing worldwide. The small bowel is well known to be a preferred site for melanoma metastases. In 60% of patients who died of disseminated melanoma, the gastrointestinal (GI) tract was affected, but only 1% to 4% of GI metastases were clinically diagnosed ante mortem. CASE REPORT: In this case we describe a report of a 71 years old male admitted to the hospital with a combination of two possible complications of GI metastatic melanoma: obstruction and GI bleeding. Past medical history reveals a malignant cutaneous melanoma excised 5 years before. DISCUSSION: Symptoms of small bowel involvement are frequently unspecific which leads to a late diagnosis often made only after complications, such as intestinal obstruction, massive gastrointestinal bleeding and perforation. In most cases, the diagnosis of melanoma metastasis was made only after surgery, which proved to be life-saving. We have searched literature for these complications and their relative treatment. CONCLUSIONS: Modern imaging techniques are recommended in order to obtain an early diagnosis. Surgical resection is the only treatment in patients with resectable metastatic intestinal melanoma. KEY WORDS: Acute abdomen, Metastatic melanoma, Small-bowel, Surgery.

Therapeutic strategies for perforated jejunal diverticulitis. A case report.

AIM: The jejuno-ileal diverticulosis is an unusual disease which affects elderly people and its complications can be fatal due to delayed diagnosis. The most frequent complication of jejunal diverticulitis is the perforation. CASE REPORT: In this report we describe a case of elderly patient presenting with acute abdominal pain and fever. The patient underwent to an urgent exploratory laparotomy that revealed a perforated small bowel diverticulum. An intestinal resection with primary anastomosis was performed. DISCUSSION: Jejunal diverticulosis often presents with non-specific symptoms like intermittent abdominal pain, dyspepsia, bloating or abdominal fullness and constipation. When, instead, it incurs a complication, it presents with an acute abdominal pain. The most frequent complication of jejunal diverticulitis is the perforation, followed by acute intestinal obstruction and diverticular bleeding. The diverticular perforation is associated with a high mortality, especially among elderly patients. Nowadays the mortality is reduced because of the improvement of the diagnostic, pharmaceutical and surgical protocols. CONCLUSIONS: With this report we want to discuss about different therapeutic approaches for perforated jejuno-ileal diverticula, which depends on the severity of the disease and the general clinical condition of the patient. KEY WORDS: Acute abdomen, Surgery, Jejunal Diverticulitis.

Metastasis of the gallbladder from the breast cancer.

AIM: Metastatic lesions of the gallbladder are an infrequent clinical condition. The metastatic lesions of gallbladder from primary breast tumors are rarely described in literature. MATERIAL OF STUDY: We report a case of an 83-year-old woman who underwent cholecystectomy for cholelithiasis by video laparoscopy (VL), and in whom a metastatic lesion was detected at the histological examination of surgical specimen. For this reason, the patient was subjected to diagnostic-instrumental investigation with the aim of detecting the primary tumor, which showed the presence of infiltrating lobular carcinoma, pleomorphic variety, in the upper outer quadrant of the right breast. DISCUSSION: Breast cancer and in particular the histological type "ductal infiltrating" is frequently associated with locoregional and distant metastases, the latter especially to bones, liver, lungs and central nervous system. An analysis of literature was conducted on secondary lesions of the gallbladder from breast cancer that has allowed us to confirm the rarity of this disease only described in 18 patients: 12 from infiltrating lobular, 1 ductal origin and 2 mixed ductal and lobular infiltrating. CONCLUSIONS: The most frequent tumor histology associated with the above-mentioned metastatic localization is the metastatic infiltrating lobular carcinoma. Clinically speaking, it is difficult to suspect a metastatic localization from primary breast cancer in the gallbladder, but it is necessary to be well aware of the possibility of metastasis and to bear this in mind during the follow-up of patients with breast cancer. Although cholecystectomy is regarded as a palliative treatment in patients with metastasis in the gallbladder from breast cancer, it is intead recommended in symptomatic cases.

Vulvar endometriosis and Nuck canal.

AIM: Endometriosis is not a well-known disease and sometimes its rare onset is a pathogenetic, diagnostic and therapeutic problem. The Canal of Nuck is an embryonal rest of the parietal peritoneum that accompanies the round ligament through the inguinal canal. The perviousness of the canal of Nuck could explain the pathogenesis of vulvar endometriosis. MATERIAL OF STUDY: We reported a case of vulvar endometriosis localization, which is rather uncommon, in a patient previously operated on with cyst of Nuck. DISCUSSION: One of the most helpful instrumental exams in defining the nature of vulvar swallows is magnetic resonance, but it remains difficult to diagnose vulvar endometriosis in spite of the instrumental exam in our possession. The hypothesis of retrograde menstruation is supported by the fact that ovarian localization is the most common in this disease. Extra-pelvic localization as well as vulvar one are less common. The Canal of Nuck is an embryonal rest of the parietal peritoneum that accompanies the round ligament through the inguinal canal. CONCLUSIONS: Endometriosis could be taken into consideration in differential diagnosis of vulvar swellings, and for this reason it is necessary to carry out a histological exam in every operated vulvar neoformation. We suggest vaginalis-peritonei duct contamination as a possible pathogenesis mechanism of this disease.

Gastric paraganglioma: a case report and a review of the literature.

AIM: Paragangliomas are neural crest-derived neuroendocrine tumors, originating from paraganglia, which are dispersed neuroendocrine organs characterized by catecholamine and peptide-producing cells. With an annual incidence estimated at 1/100,000, paragangliomas represent 10% of catecholamine secreting tumors. MATERIAL OF STUDY: We report a case of a 76-year-old man who was submitted to a subtotal gastrectomy with omentectomy and gastrojejunal anastomosis. The Hystologic exam has revealed an ulcerative polypoid gastric carcinoma with cell poorly cohesive and infiltration of the muscular gastric wall and an incidental parietal gastric lesion which was a paraganglioma with immunocytochemical investigations positive for NSE and negative for CD117, S100, CD34 e SMA. DISCUSSION: Pheochromocytoma indicates exclusively tumors arising from the adrenal medulla, while the extra-adrenal paraganglioma suggests tumors of the chromaffin cells with other locations. Gastric or paragastric localization, as in our case, is very rare for these neoplasms, and in literature there are only isolated case reports. Genetical predisposition is observed in 30% of these tumors and can be responsible of hereditary disease characterized for differences in tumor distribution, catecholamine production, risk of metastasis, and association with others types of tumors. CONCLUSION: In asymptomatic patients and when biochemical and clinical suspicion of neuroendocrine tumor is strong, you have to perform anatomical and functional investigations to detect these neoplasms. The first line treatment for resectable tumors is complete surgical resection, that can be performed with open surgery or laparoscopic technique. Surgical therapy is also indicated to palliative intent when a complete eradication of disease is not achievable for metastatic status of malignancies.