Mucinous appendiceal neoplasms: Report of a case and brief literature review.

INTRODUCTION: Appendiceal tumors are rare neoplasms detected in about 2 % of appendicectomies. The clinical presentation is often unspecific, varying from unspecific abdominal pain or presenting as an acute appendicitis or being asymptomatic. CASE PRESENTATION: We present a case of a patient presenting as an acute appendicitis with a mucocele, and then classified as HAMN. The patient was treated with initial laparoscopic approach and then conversion in laparotomy with appendectomy. Histology demonstrated a high grade appendiceal mucinous neoplasm limited to submucosa (pT3), with concomitant acute phlegmonous appendicitis. The patient was subsequently sent to a referral center where a right hemicolectomy with HIPEC was performed. DISCUSSION: HAMN is a rare entity, only recently classified as a new kind of appendiceal mucinous neoplasm. Due to the supposed higher aggressivity, HAMN must be treated as an appendiceal adenocarcinoma. The treatment of this rare entity is not yet well standardized, because of the rarity of this disease. CONCLUSION: HAMN is a very rare tumor. In the emergency setting, it is mandatory to avoid rupture of the appendix, to minimize the risk of developing pseudomyxoma peritonei. Pathology is essential for further decisions in these patients and plays a very important role in treatment and prognosis.

A rare case of pneumatosis cystoides intestinalis with bowel perforation and secondary sepsis.

MATERIALS AND METHODS: We present here the case of an 83 y.o. male with intestinal perforation from pneumatosis cystoides intestinalis and consequent sepsis. RESULTS: The patient underwent urgency intestinal resection in our institute, with complete restitution ad integrum Discussion: Pneumatosis cystoides intestinalis is a rare affection, which can be categorized as primary (15%) or idiopathic( 85%). The clinical appearance can be very variable from patient to patient, since it can be completely asymptomatic or start with life-threatening clinical presentation of bowel perforation and sepsis. There are various theories about the formation of the gas bubbles trough the intestinal wall. The mechanical theory assumes that the gas, tearing trough the intestinal wall seeps trough it. The bacterial theory assumes that antibiotic treatment, such as with metronidazole, allows the creation of gas by microbiological elements like Clostridium Perfringens or Clostridium Difficile. The pulmonary theory, instead, assumes that air released from ruptured alveoli gets into the mediastinum and retro peritoneum, reaching the intestinal tract. The treatment is conservative most of the times, except for the cases of intestinal perforation and sepsis. CONCLUSIONS: Despite of the long history of the disease, with the first description in 1783, little is known nowadays about PCI, due to the rarity of symptomatic disease. Further studies are needed to better evaluate the aetiology of the condition, and the prognostic criteria, which may be very important for clinical decisions about conservative or surgical treatment. KEY WORDS: Diagnosis, Pneumatosis cystoides intestinalis, Peritonitis, Therapy.

Multiparametric ultrasound in the diagnosis and monitoring of ischemic colitis: description of a case of ischemic colitis of the right colon and revision of the literature.

The aim of this paper is to describe the usefulness of multiparametric US in the diagnosis and subsequent follow-up of a case of right-side ischemic colitis and to present a review of the data reported in the literature. Ischemic colitis is frequently diagnosed in the field of gastroenterology. Diagnosis is usually based on the outcome of endoscopy and histological examination, and in case of right-side ischemic colitis also on the results of contrast-enhanced CT. In the described case, multiparametric US indicated the diagnosis including a prognostic judgment, and during follow-up US-monitored patency of the stents positioned under angiographic guidance. One of the available US techniques, CEUS, seems to have a special role in the detection of residual vascularization of the gastrointestinal tract affected by ischemia. However, before introducing this method into daily clinical practice, further studies are required to confirm its diagnostic accuracy.

Strain elastography in Crohn's disease: the role of visual observation and semiquantitative parameters.

Strain elastography is a recently developed ultrasound method that seems to contribute to the diagnosis and monitoring of inflammatory bowel diseases. This pictorial essay aims to present the feasibility of strain elastography in clinical practice by comparing visual observation and semiquantitative parameters with endoscopic or radiological images in some common cases of Crohn's disease. In our opinion, strain elastography with visual observation is easily performed in connection with B-mode ultrasound and color Doppler imaging and may provide relevant information. Strain elastography with the elaboration of semiquantitative parameters is not as immediate as the visual observation method, but it seems to provide more objective data and seems more appropriate for monitoring the evolution of the disease. However, for the elastographic method to extensively contribute in inflammatory bowel diseases, standardization and further studies are required to confirm the promising results already reported in the literature.

Contrast-enhanced ultrasonography in clinical practice in Crohn's disease: feasibility of destruction/replenishment method and software analysis.

The aim of this Pictorial Essay is to evaluate the feasibility in the clinical practice of CEUS destruction/replenishment method and time intensity curve (TIC) analysis using the available software in patients with Crohn's disease. The ultrasound (US) procedure using contrast agent is briefly described, elaboration and analysis of the US sequences are explained in detail, and some advantages and disadvantages of the method are highlighted. The Authors suggest that the destruction/replenishment method is useful and time-saving in Crohn's disease if multiple measurements are required on intestinal portions adjacent to each other or in different locations.

Extragenital malignant mixed mesodermal tumor: A case report.

INTRODUCTION: Primary malignant mixed mesodermal tumor (MMMt, also called malignant mixed Mullerian tumor and designated in the WHO classification of female genital tract neoplasms as carcinosarcoma) is an infrequent tumor that develops usually in the uterus and more rarely in the ovary. Extragenital tumor, including primary peritoneal MMMt, is an extremely rare and aggressive neoplasm with only few case reported in the literature. PRESENTATION OF CASE: We report a case of a 70-year's old female who presented with nausea and abdominal discomfort for 6 months. Workup revealed an abdominal mass. Patient was treated with surgical removal in a general hospital. DISCUSSION: Most peritoneal carcinosarcomas originate in the pelvic peritoneum, followed by decreasing frequency in the serosal surface of the colon, retroperitoneum, anterolateral abdominal peritoneum, and omentum. Surgical excision is the most effective treatment in carcinosarcomas. A complete cytoreduction, with resection of cancer to a status of no evidence of disease by the surgeon's unaided eye should be attempted. CONCLUSION: Owing to the rarity of the disease, limited data regarding the management of peritoneal MMMT exists. Recommendations for the treatment of MMMT are based on individual cases only. In our case, the patient is alive with a follow-up of 15 months and she did not receive any cycle of chemotherapy.

Real-time elastography in Crohn's disease: feasibility in daily clinical practice.

Ultrasound (US) is the first-line investigation in patients with abdominal symptoms and it has a role in the diagnosis and monitoring of inflammatory bowel diseases. Strain elastography (SE) is a US method for estimating tissue elasticity. This method is still not routinely used in clinical practice, although it is suggested by the EFSUMB Guidelines for the characterization of intestinal stenosis in Crohn's disease. The purpose of this Pictorial Essay is to confirm the feasibility of elastography in Crohn's disease in clinical practice by comparing elastography images with corresponding endoscopic or radiological images. At present, diagnostic accuracy of SE is reported in the literature only in connection with detection of bowel wall fibrosis in advanced cases of Crohn's disease. However, in our opinion, SE can add useful diagnostic information to grayscale and color Doppler US by providing a more accurate characterization of the bowel wall in the various manifestations of Crohn's disease.

Feasibility of CEUS and strain elastography in one case of ileum Crohn stricture and literature review.

Contrast-enhanced ultrasonography (CEUS) and strain elastography (SE) are diagnostic imaging methods, which are still not routinely used in the clinical management of inflammatory bowel diseases. However, there are studies in the literature reporting on the use of both CEUS and SE in patients with bowel obstruction due to Crohn's disease, documenting the usefulness of these two methods in the differentiation between inflammation and fibrosis affecting the bowel wall. The aim of this case report is to evaluate the usefulness of CEUS and SE performed in a patient with Crohn's disease, who was admitted to hospital with bowel obstruction due to terminal ileal stricture and submitted to ileocecal resection. CEUS and SE identified and to some extent also characterized the inflammatory and fibrotic processes affecting the bowel wall. Macroscopic and microscopic examinations of the surgical specimen confirmed the presence of inflammatory phenomena (exudates, ulcers, and fistulas) and fibrosis as suggested by ultrasound (US) imaging methods.

Diagnosis of one small bowel tumor: the role of conventional ultrasound and elastography.

Neuroendocrine tumors are the most common primary tumors of the small bowel, but diagnosis is usually delayed as the lesions are small and symptoms are mild or nonspecific. Diagnosis of this disease is currently based on radiologic or endoscopic findings. Ultrasound (US) is used as a first-line examination in patients with abdominal symptoms, as this technique permits an overall view of the gastrointestinal tract providing diagnosis of inflammatory and/or neoplastic disorders in a large proportion of patients. The aim of this case report is to describe the feasibility and diagnostic accuracy of elastography in the diagnosis of a tumor of the ileum. The patient underwent conventional gray-scale US and elastography before surgery and these examinations were repeated postoperatively on the surgical specimen confirming preoperative outcome.

Feasibility of real-time strain elastography in colonic diseases.

Real-time strain elastography is not routinely performed in clinical practice for characterizing gastrointestinal tract diseases, and there are few studies in the literature on the subject. The recent EFSUMB guidelines suggest the use of this method in the diagnosis of neoplastic lesions and in the characterization of bowel strictures in patients with Crohn's disease. The purpose of this pictorial essay is to evaluate the feasibility of strain elastography in some pathologies of the colon frequently encountered in daily clinical practice and to compare elastography images with corresponding endoscopic and radiographic images. In our opinion, strain elastography is useful for characterizing diseases of the colon as it can add valuable diagnostic information to grayscale ultrasound imaging. However, diagnostic accuracy and clinical relevance of this information should be confirmed by further prospective research-targeted studies.

Contrast-enhanced sonography in the diagnosis of hepatic hemangiomas: atypical appearance due to the washout of microbubbles.

Contrast-enhanced sonography (CEUS) examination permits identification of hemangioma of the liver in most cases. This method is particularly useful when the ultrasound pattern is atypical on standard grayscale examination. CEUS appearances suggestive of hemangioma are peripheral globular enhancement, progression of enhancement toward the center of the nodule, and persistence of enhancement in the late phase. We present seven cases of hemangioma, which were atypical on CEUS examination due to washout during the portal and late phases, resulting in a hypoenhanced appearance compared with the adjacent liver parenchyma.

Referrals for bowel ultrasound in clinical practice: a survey in 12 nationwide centres in Italy.

BACKGROUND: The value of ultrasound (US) in assessing gastrointestinal diseases is well documented, but its demand in clinical practice is unknown. This survey evaluated the demand for bowel US in Italy. METHODS: Twelve sonographers of the Gastroenterology Section of the Italian Society of Ultrasound participated in a 1-month survey; they compiled a questionnaire assessing total number of patients referred for abdominal US and for gastrointestinal tract US, type of referring physician, indications and results of examinations. RESULTS: The survey included 2424 examinations, 586 of which (24%) investigated the gastrointestinal tract: 280 for signs or symptoms and 268 for follow-up of pre-existing gastrointestinal diseases. Referring physicians were mainly gastroenterologists (78%) and general practitioners (13%). Organic lesions were found or suspected in 292 examinations. CONCLUSIONS: Bowel US is used in Italy in routine practice, mainly by gastroenterologists and general practitioners, both for follow-up of pre-existing diseases and for gastrointestinal complaints.

Contrast-enhanced sonography in the diagnosis of acute mesenteric ischemia: case report.

Acute mesenteric ischemia is a serious condition associated with high mortality. Multislice CT and magnetic resonance angiography have proved accurate in diagnosing this pathology, which requires a prompt diagnosis to start appropriate therapy. We report the case of an 87-year-old woman with acute mesenteric ischemia, in whom contrast-enhanced sonography visualized the occluded superior mesenteric artery and the infarcted portion of the intestine.

Contrast-enhanced sonography of a hepatocellular carcinoma undergoing spontaneous necrosis.

Spontaneous necrosis of hepatocellular carcinoma (HCC) is rare. We report the case of a 72-year-old woman with an HCC nodule that underwent necrosis after sonographically guided needle biopsy. Baseline sonographic examination revealed only a nonspecific change in the echogenicity of the lesion. Subsequent necrosis was suggested on contrast-enhanced sonographic examination and was confirmed on spiral CT.