Surgical management of primary crohn's disease. descriptive study about 226 patients.

BACKGROUND: The surgery is required in more than 80% of patients with Crohn's disease (CD). Studies before confirm the specific genetic variation of CD in the Tunisian population compared with the others ethnic groups. AIM: This article aims to study the epidemiological, anatomical and therapeutic principles of surgical forms of CD in a cohort of Tunisian patients. METHODS: We report a retrospective study from January 1998 to September 2010 that studied 226 patients originated only from Tunisia (in North Africa), operated on for MC. We had been interested in epidemiological, anatomical, clinical, therapeutic, topographic progression of the disease, the procedure and the postoperative follow-up. RESULTS: The median age was 33 years. The average time between the onset of the disease and the surgical procedure was 31 months. The diagnosis of CD was established preoperatively in 213 patients (94%). The diagnosis was made intraoperatively because of an acute complication in 5 cases (2.2%) and postoperatively in 8 cases (3.5%). The most common location was the ileocecal junction in 184 cases (81.4%). Achieving the most common was the mixed form (stricture and fistula) in 123 cases (54.4%). Operative mortality was 0.04% (n = 1). Specific morbidity was 8.4% (n = 19). In long term, a surgical recurrence was noted in 17 patients (7.5%). In multivariate analysis the independent risk factors for surgical recurrence were: smooking (p = 0.012, ORs = 3.57) and post-operative medical treatment (p = 0.05, ORs = 2.6). CONCLUSIONS: Achieving stenosing and fistulizing the ileocecal junction is the most frequent surgical form in Crohn's disease. Our series is unique for a lower rate of the postoperative recurrence (7.5%).

Anal imperforation in adults: Diagnostic difficulties and therapeutic options.

Anorectal malformations are congenital anomalies ranging from simple perineal fistulas to complex malformations. They are usually treated inchildhood, and exceptionally in adult. We herein report the case of a 22 years aged patient and relate the diagnosis difficulties and therapeuticoptions. She consulted for anal imperforation discovered since birth. Initially, His parents refused the surgical management. It was an analimperforation with a vestibular fistula. The patient was operated by a low approach. She had a disconnection of the recto-vestibular fistula,dissection of the anal canal and a perineal posterior transposition. Postoperative course was uneventful. The evaluation of continence usingKelly's score found good Functional result.

Laparoscopic ileo-cecal resection: the total retro-mesenteric approach.

BACKGROUND: Ileo-cecal resection is the most performed procedure in Cohn's disease. In the last decades, the laparoscopic approach became the gold standard. The dissection can be lateral to median or median to lateral. In non-malignant diseases as it is the case for Crohn's disease, the most performed dissection approach is the lateral to median. Herein, we describe a technique performed in our department: the total retro-mesenteric approach. METHOD: The procedure requires 4 trocars with a 10- to 12-mm median suprapubic trocar. The telescope is placed in this trocar. The dissection will begin with the opening of the mesentery root creating a retro-mesenteric tunnel. This dissection gives a direct visualization of the duodenum, of the ureter and the gonadic vessels which guarantees a safe procedure considering the importance of the inflammation in this disease. At the end of the retro-mesenteric step, the right colon is only attached to the Toldt's fascia. The transection of the mesentery is done next to the bowel wall leaving at the end the choice to the surgeon to perform an extra- or endocorporeal anastomosis. RESULTS: This retro-mesenteric approach has been used in our department since 2004. Until May 2013, 89 patients underwent laparoscopic resection for Crohn's disease with a mean operative time of 130 min, a morbidity rate of 6 % and a laparoconversion rate of 13.6 %. CONCLUSION: We describe the total retro-mesenteric approach in the ileo-cecal resection for Crohn's disease. The approach is considered to be safe allowing the surgeon to perform a dissection far from the inflammatory site and allowing a visual identification of the duodenum and the right ureter. The morbidity of the procedure is equivalent to the other dissection techniques.

Laparoscopic resection of gastric stromal tumors.

Gastro-intestinal stromal tumors (GIST) are the most common mesenchymal gastrointestinal tumors. The Gastric location represents 60% of cases [1,2]. Complete surgical excision remains the treatment of reference for the localized forms. This surgery can be made by laparoscopy when the lesion's size doesn't exceed 5 cm. Some principles must e respected: a mono-block complete surgical resection, with healthy margins and without effraction. This technique will be reserved for trained teams and for selected cases according to the size and location. We herein try to explain the surgical laparoscopic excision of gastric stromal tumors explaining .

[Surgical management of entero-vesical fistulas in Crohn's disease]. / Traitement chirurgical des fistules entéro-vésicales secondaires à la maladie de Crohn.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory disease of the intestine that can cause an attack by contiguity of the urinary tract. Although the shape is common and fistulizing 35% of all patients with CD, entero-urinary fistulas are rare and only seen in 2-8% of patients. aim: To report the frequency of occurrence of this complication among the group of surgical forms of CD. Describe the different pathophysiological mechanisms of occurrence of entero-vesical fistula (EVF) during the CD. methods: We report, retrospectively, seven observations of EVF complicating MC made during the period from 01/01/1998 until 31/12/2010. results: The mean age of patients was 30 years. There were 3 men and 4 women. All patients had clinical signs and radiological EVF. In six patients, CD was ileo-caecal and the ileo-vesical fistula was between the last loop and the bladder. In one patient, the CD was located only in colon, and the fistula was between sigmoid colon and bladder. Level of the bladder, it was a false EVF in five patients and a true EVF in two patients. In these last two, the fistula of 2 mm, was on the top of the bladder. Treatment consisted in all cases by a disconnect between the digestive tract and bladder, resection with restoration of digestive continuity, and if the case of true EVF, a freshening the edges of the fistula with suture of the bladder's wall and drainage. The postoperative course was uneventful in six patients and marked by an outbreak intraperitoneal abcess in one patient who had evolved under medical treatment. After a mean of eleven months, no recurrence surgery was noted. CONCLUSION: Despite advanced treatment in the context of CD, the indication in EVF is a surgical treatment. Surgery helps fight against the consequences of septic urinary tract, but also to launder bowel disease and reduce the risk of recurrence in the short term.

Fortuitous detection of adult malrotated ectopic kidney during acute appendicitis: A unique case report.

INTRODUCTION AND IMPORTANCE: Renal ectopia, a rare congenital anomaly, can occur in various body regions and may be associated with other abnormalities. It is often asymptomatic, commonly found incidentally, as in our 70-year-old patient during appendicitis exploration. This case highlights the importance of recognizing renal ectopia and associated anomalies, such as vascular abnormalities and renal malrotation, which may predispose patients to potential complications and require vigilant monitoring for urinary tract infections and lithiasis events, as well as potential challenges during laparoscopic surgical procedures, as in our appendectomy case. CASE PRESENTATION: A 70-year-old female presented with right iliac fossa pain and elevated inflammatory markers. Abdominopelvic CT scan confirmed uncomplicated appendicitis and revealed a right ectopic and malrotated kidney. Laparoscopic appendectomy was performed without complications. Postoperative recovery was uneventful, and discharge occurred one day post-procedure. A four-week follow-up was scheduled to monitor for urinary infection and stone formation, with initiation of hygienic and dietary measures. CLINICAL DISCUSSION: Renal ectopia, a congenital anomaly, frequently positions the kidneys in the pelvic region. Iliac ectopias are often confused with pelvic or abdominal ectopias. Ectopic kidneys can result in complications like vesicoureteral reflux, urinary tract infections, or kidney stones. Despite being typically left-sided, our patient presented with right-sided renal ectopia with malrotation. Despite lacking urinary symptoms, a urological consultation was advised due to the potential risk of infection or kidney stones. Surgical intervention is reserved for complication management. CONCLUSION: Renal ectopia, a rare congenital anomaly, can be asymptomatic but often coincides with other renal or vascular issues. Early detection and accurate imaging are essential, emphasizing clinical vigilance and interdisciplinary collaboration for better patient care.

A laparoscopic odyssey: Managing giant colonic lipoma-induced colo-colonic intussusception - A case report.

INTRODUCTION: Colonic lipomas (CL) are rare non-epithelial benign tumors. Giant Colonic lipomas (>4 cm) can cause serious complications such as bowel obstruction, massive bleeding, perforation, and intussusception. Early diagnosis is difficult and preoperative discrimination between malignant lesions and large cl is challenging. Surgical resection is the cornerstone of the treatment. CASE PRESENTATION: A 57-year-old woman presented to our surgical department complaining about intermittent crampy abdominal pain with an alternation of diarrhea and constipation for the last 7 months. After radiological and endoscopic investigations, the diagnosis of colo-colonic intussusception caused by colonic lipoma was confirmed. The patient underwent laparoscopic enucleation and a histopathological examination of the specimen confirmed the diagnosis of colonic lipoma. DISCUSSION: Colonic lipomas (CL), though rare (0.2 to 4 %), are the third most common benign colon tumors. Typically affecting adult women (57 %), these non-epithelial growths can vary in size from 2 mm to 30 cm, often remaining asymptomatic until complications arise. Colonic lipomas may lead to intussusception or bowel obstruction, with clinical presentation depending on size and location. Diagnosis relies on abdominal CT scans or MRI, while treatment options include surveillance, endoscopic, or surgical resection. Laparoscopic approaches offer favorable postoperative outcomes, although precise localization remains a challenge. Endoscopic techniques are limited, particularly for larger or difficult-to-access lipomas, necessitating expert care. CONCLUSION: Giant colonic lipoma can cause colonic intussusception leading to emergency operation. We think that laparoscopic enucleation seems to be the ideal treatment choice, especially when the malignancy cannot be excluded.

Case report: Rare benign colorectal intussusception due to rectal polyp treated non operatively.

INTRODUCTION AND IMPORTANCE: Intestinal intussusception is rare in adults, involving telescoping of one intestinal segment into another. Commonly associated with colonic lesions, it presents as acute obstruction. Diagnosis relies on CT. We report a rare case of colorectal intussusception due to a polyp, managed by endoscopic polypectomy. CASE PRESENTATION: We present a case of a 74-year-old man with chronic constipation, who presented with acute abdominal pain, vomiting, and cessation of bowel movements. Hemodynamically stable, he had a distended abdomen. We diagnosed acute bowel obstruction secondary to colorectal intussusception via CT scan. Surgery was planned after resuscitation. However, after induction of general anesthesia, the procedure was postponed due to a significant diarrheal episode and resolution of the abdominal distension. A subsequent colonoscopy revealed a 10 mm polyp, which was excised endoscopically. The patient's recovery was smooth, with no recurrence after a one-year follow-up. CLINICAL DISCUSSION: Intestinal intussusception, rare in adults, primarily affects the small intestine but may involve the colon, often associated with organic lesions or postoperative adhesions. While colocolonic intussusceptions, mostly malignant, may stem from benign causes occasionally, symptoms are nonspecific, with common pain. Diagnosis relies on CT scans, with surgery typically required, except in select cases. CONCLUSION: Colorectal intussusception, rare in adults, may necessitate laparotomy. Spontaneous symptom resolution enables conservative management. Clinician awareness is vital to prevent unnecessary and risky surgeries, given its rarity and potential for favorable outcomes sans intervention.

Actinomycosis as a rare cause of acute appendicitis: Case report and comprehensive literature review.

INTRODUCTION AND IMPORTANCE: Actinomycosis is a rare, chronic bacterial infection caused by Actinomyces species. While it commonly affects the cervicofacial region, thorax, and abdomen, appendicular involvement is extremely uncommon. This case report details the presentation, diagnosis, and management of a 45-year-old female patient with acute appendicitis secondary to actinomycosis. CASE PRESENTATION: A 45-year-old woman, with an 8-year intrauterine device history, presented with three-day right iliac fossa pain, vomiting, and stable vital signs. Laboratory tests revealed an inflammatory syndrome. Suspecting acute appendicitis, a CT scan confirmed a swollen 10 mm appendix. Laparoscopic surgery revealed a phlegmonous appendix, leading to an uncomplicated appendectomy. Pathological examination confirmed actinomycotic granules, supporting the diagnosis of actinomycosis appendicitis. The patient received 18 million units of intravenous penicillin G daily for 6 weeks followed by a 6-month course of oral amoxicillin (1 g three times daily) thereafter, showing favorable progression with no symptoms. Normal clinical and ultrasound follow-ups were observed at one year. CLINICAL DISCUSSION: Appendiceal actinomycosis is a rare condition. Women, especially those with intrauterine contraceptives, experience an increase in cases due to chronic inflammation. Typically underdiagnosed, actinomycosis mimics other conditions, presenting with nonspecific symptoms. Laboratory results offer limited assistance, and histological confirmation is crucial. Histopathological examination is mandatory for diagnosis confirmation. Management involves surgical resection and prolonged penicillin-based antibiotics, providing a favorable prognosis with low mortality. CONCLUSION: This case underscores the importance of considering rare etiologies, such as actinomycosis, in the differential diagnosis of appendicitis. Timely recognition and management are crucial for optimal patient outcomes.

A rare case report of an appendico-sigmoid fistula complicating untreated acute appendicitis: Unraveling complexity in diagnosis and treatment.

INTRODUCTION: Appendiculocolonic fistulas, often arising from benign conditions like abscess-forming appendicitis, manifest subtly. This case emphasizes their rarity, intraoperative discovery during acute appendicitis, and explores diagnostic intricacies, sensitive imaging, and distinctions in managing benign versus malignant cases. CASE PRESENTATION: A 23-year-old intellectually disabled patient, lacking regular medical follow-up and surgical history, presented to our emergency department with persistent right iliac fossa pain six months ago. Due to financial constraints, a CT scan was not performed despite an inflammatory syndrome, and the patient left against medical advice. Currently experiencing the same symptoms, investigations led to the diagnosis of acute appendicitis with a probable appendico-sigmoid fistula. Surgical exploration confirmed the appendico-sigmoid fistula and the presence of an uncomplicated Meckel's diverticulum. A conservative approach, including appendectomy, Meckel's diverticulum resection, and sigmoid fistula suturing, yielded favorable results. CLINICAL DISCUSSION: Appendiculocolonic fistulas often arise from acute or chronic appendicitis with local abscess formation. Our case highlights the unusual progression of untreated acute appendicitis, evolving into an appendico-sigmoid fistula. While generally benign, documented cases of malignant causes, such as appendiceal cancer, exist. Diagnosis is intricate, requiring diverse methods, with abdominal CT as a sensitive imaging tool. Conservative approaches are generally recommended for benign cases. CONCLUSION: Appendiculocolonic fistulas, though rare, pose a clinical challenge due to their elusive symptoms. Primarily associated with benign conditions, notably abscess-forming appendicitis, or, as in our case, untreated acute appendicitis. This case underscores the role of abdominal CT in precise diagnosis, guiding treatment decisions based on the lesion's nature.

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.

A rare case report: Primary isolated hydatid cyst of the spleen- diagnosis and management.

INTRODUCTION AND IMPORTANCE: Hydatid disease is widespread in agricultural regions and globally. Tunisia is notably affected in the Mediterranean. Although liver involvement is common, splenic hydatidosis is rare, with incidence worldwide ranging from 0.5 % to 4 %. Surgery, particularly total or partial splenectomy, remains the primary treatment. We present a unique case of isolated splenic hydatid cyst successfully managed by total splenectomy. CASE REPORT: A 40-year-old Tunisian farmer presented with persistent pain in the left hypochondrium for 4 months, accompanied by a sensation of heaviness. Physical examination revealed splenomegaly, and laboratory tests showed a positive Indirect Hemagglutination test for Echinococcus sp. (titer >160). Thoracoabdominal CT scan revealed a 10 cm splenic hydatid cyst. Surgery involved total splenectomy via an extended left subcostal approach. Postoperative recovery was uneventful, with successful albendazole therapy and vaccination following splenectomy. During biannual follow-up, the patient remained asymptomatic and did not present with any other hydatid localization. CLINICAL DISCUSSION: Splenic hydatid cyst is rare. Diagnostic and therapeutic advancements are crucial for its management. Therapeutic options include total splenectomy, spleen preservation, and percutaneous interventions. However, these approaches carry unique risks and benefits. Close monitoring and individualized management are essential to ensure optimal outcomes. CONCLUSION: Diagnosis of splenic hydatid cysts is challenging due to their often asymptomatic nature and lack of specific signs. With no standardized management protocols available, personalized treatment strategies are essential. Further research is crucial to improve treatment approaches and outcomes for this rare yet clinically important condition.

Exceptional vascular variants during oncological right colectomy: Case reports.

INTRODUCTION: Carcinological right colectomy with complete D3 mesocolon excision has to be guided by vascular variants in order to avoid complications especially in exceptional cases as illustrated by our two cases. CASE PRESENTATIONS: Two women had right colectomies with compete D3 mesocolon excision via laparotomy for right colon tumors with a non-modal anatomy: an X-shaped relationship between the superior mesenteric artery and the superior mesenteric vein and a Y-shaped superior mesenteric vein, an ileocolic artery behind the two trunks, a right colic artery behind the left trunk, and the middle colic artery anterior to the main trunk of the superior mesenteric vein respectively. DISCUSSION: Our cases illustrated extremely rare vascular variants during right colectomy with complete mesocolic excision. These variants should be identified based on the computed tomography with coronal reconstructions allowing to guide surgical procedure before the operating room in order to anticipate per-operative difficulties and reduce morbidity. CONCLUSIONS: Vascular anatomical study based on computed tomography with coronal reconstructions was mandatory before right colectomy with complete mesocolic excision and D3 lymphadenectomy.

Reversed midgut rotation revealed by cecal volvulus in the elderly: A case report.

INTRODUCTION: Reverse midgut rotation constituted an extremely rare intestinal malrotation. Its recognition in the elderly was challenging as in our case revealed by cecal volvulus. CASE PRESENTATION: A 78-years old man consulted for diffuse abdominal, vomiting, bowel movement and passing gas inability. Computed tomography concluded to cecal and last ileum loop volvulus with small intestine dilation upstream. Emergent laparotomy confirmed the existence of a cecal volvulus associated to a reversed midgut rotation non diagnosed at computed tomography before surgery. A Ladd' procedure was carried out. An isoperistaltic side-by-side ileocolic manual anastomosis was performed. DISCUSSION: Our case illustrated an extremely rare reversed midgut rotation in the elderly accounting for 2 to 7 % of all embryologic midgut malrotation anomalies. It could be revealed by mobile right colon volvulus as in our case, whole midgut volvulus, retro-arterial tunnel pressure transverse colon stenosis, or Ladd' bands duodenojejunal obstruction. Its recognition at the elderly was challenging and needed careful computed tomography combined signs determination. Surgical treatment accounted for the treatment of choice for reversed midgut rotation especially in emergency settings as in our case. Ladd' procedure is still the most performed procedure. CONCLUSIONS: Reverse midgut rotation constituted an extremely rare congenital intestinal malrotation. Its diagnosis in the elderly was challenging implicating careful interpretation of computed tomography.

Arteriovenous gastric malformation: A challenging diagnosis. A case report.

INTRODUCTION: Gastro-intestinal bleeding etiological diagnosis could be challenging especially for rare etiologies as it was the case of our patient having an arteriovenous gastric malformation. CASE PRESENTATION: A 50-years old man consulted for hematemesis. Esophagogastroduodenoscopy didn't show bleeding signs. Angio-scan revealed an arteriovenous gastric malformation. Median laparotomy revealed multiple radiologically unsuspected great omentum arteriovenous malformations and confirmed the existence of this arteriovenous malformation in the posterior part of the lesser curvature guided by per-operative esophagogastroduodenoscopy. Atypical gastrectomy was performed. DISCUSSION: Our case illustrated a rare life-threatening condition with a challenging diagnosis. Arteriovenous gastric malformation accounted for 1 to 2 % of nonvariceal upper gastrointestinal bleeding. Great omentum localization corresponded to an exceptional condition that had been reported in only one adult patient and one childhood case. Its pathogenesis is still unknown. CONCLUSIONS: Arteriovenous gastric malformation had to be considered in case of normal endoscopic esophagogastroduodenoscopy. Computed tomography had to be done for both diagnosis and therapeutic purposes.

Azathioprine and Acenocoumarol Drug Interaction in Patients with Crohn's Disease: A Case Report.

BACKGROUND: Acenocoumarol is an anticoagulant with numerous drug reactions. We report here, an unusual interaction between acenocoumarol and azathioprine. CASE PRESENTATION: A 35-year-old woman, treated with acenocoumarol for thrombosis of the superior mesenteric vein, was prescribed azathioprine for Crohn's disease. Three days later, INR values decreased from 2.36 to 1.48. The dose of acenocoumarol had to almost be doubled to reach an INR value of 2.56. The interaction between azathioprine and acenocoumarol was then suspected. Few similar cases of interactions between azathioprine and another coumarin derivative, warfarin, have been reported. To our knowledge, this is the second case of such interaction reported with acenocoumarol in literature. CONCLUSION: Thus, despite the rarity of this interaction reporting, we draw attention to the importance of close monitoring of INR values in patients treated with acenocoumarol associated with azathioprine.

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.

An exceptional cause of dyspnea: The uncommon case report of the association between Chilaiditi syndrome and diaphragmatic eventration.

INTRODUCTION AND IMPORTANCE: Chilaiditi's syndrome, characterized by the abnormal positioning of the intestine between the diaphragm and liver, and diaphragmatic eventration, a condition marked by the permanent elevation of one side of the diaphragm, are both exceedingly uncommon medical conditions. Their co-occurrence is even rarer, with only a handful of documented cases in medical literature. CASE PRESENTATION: A 71-year-old male patient initially presented with shortness of breath and was subsequently diagnosed with both Chilaiditi's syndrome and diaphragmatic eventration. His medical history included episodes of abdominal pain, constipation, and a prior colonoscopy that revealed no abnormal findings. Thorough physical examinations and imaging studies confirmed these diagnoses, and the patient's treatment was conservatively managed with intravenous fluids and laxatives, resulting in a significant improvement in his symptoms. Subsequent regular follow-up assessments showed no recurrence of symptoms. CLINICAL DISCUSSION: Chilaiditi's sign/syndrome is a rare condition involving colon interposition between the liver and diaphragm, often diagnosed incidentally during imaging. It mainly affects older men and can cause abdominal symptoms. Management is typically conservative, but surgery may be needed if symptoms persist or complications arise, especially in cases of colonic volvulus or ischemia. When encountering diaphragmatic air, consider a differential diagnosis to avoid unnecessary surgery. Simultaneous hepatodiaphragmatic colonic interposition and diaphragmatic eventration is extremely rare, with uncertain causation. CONCLUSION: This case highlights the rarity of the combination of Chilaiditi's syndrome and diaphragmatic eventration. Conservative management led to a significant improvement in symptoms, underscoring the importance of early recognition to prevent complications.

Revelation of Rapunzel syndrome: A rare case report of gastric trichobezoar-induced acute purulent peritonitis.

INTRODUCTION AND IMPORTANCE: The Rapunzel syndrome embodies an uncommon variation of trichobezoar, predominantly observed among individuals with a history of psychiatric conditions, trichotillomania, and trichophagia. This combination of factors predisposes to the eventual formation of gastric bezoars. Trichobezoars, infrequent gastric masses composed of hair, can lead to complications if left untreated. CASE REPORT: A 19-year-old female hairdresser with a history of trichophagia sought medical attention due to abdominal pain and episodes of vomiting. With an elevated body temperature and abdominal rigidity, imaging revealed the presence of a trichobezoar, accompanied by pneumoperitoneum and intraperitoneal effusion. Urgent surgical intervention confirmed the diagnosis of generalized purulent acute peritonitis, triggered by a gastric perforation caused by a 20 cm trichobezoar with an extension into the duodenum, which defines the Rapunzel syndrome. Gastrotomy was performed to remove the trichobezoar, followed by thorough peritoneal lavage. CLINICAL DISCUSSION: Trichobezoar is a rare condition that involves the abnormal accumulation of solid substances, particularly hair, within the stomach. Known as "Rapunzel syndrome," it can extend into the duodenum or jejunum. Commonly associated with emotional disorders, trichobezoar can lead to symptoms like epigastric discomfort, vomiting, and weight loss. Diagnosis is through endoscopy, and treatments include fluid intake, endoscopic extraction, chemical dissolution, and surgical removal. Surgical intervention is often preferred, with laparoscopic approaches considered. Psychiatric management is often required for patients. CONCLUSION: This case underscores the uncommon Rapunzel syndrome presentation, emphasizing timely surgical measures and multidisciplinary care for trichobezoars causing acute peritonitis.