Evaluating aortomesenteric parameters in a tertiary center of Nepal for superior mesenteric artery syndrome diagnosis and risk factors: cross-sectional study.

Background and objectives: This study examines aortomesenteric angle (AMA) and distance (AMD), which are critical in superior mesenteric artery (SMA) syndrome. Addressing the scarcity of SMA cases, the research explores potential links with lower BMI and aims to establish normative data for diagnostic and predictive purposes, using contrast-enhanced computed tomography (CT) scans across various BMI and sex categories. Methodology: A retrospective quantitative cross-sectional study was conducted on 189 patients undergoing abdominal contrast-enhanced CT scans between December 2019 and December 2020. Ethical clearance was obtained, and participants provided informed consent. Exclusion criteria targeted specific medical histories. Patient demographics, BMI categories, and imaging data were recorded. Helical 128-slice CT scans were employed, with sagittal-oblique multiplanar reconstructions for parameter assessments. Statistical analysis utilized SPSS 26.0, including Pearson correlation coefficients and mean calculations. Results: The study reveals a mean AMA of 54.07°±8.53° and a mean distance of 16.25±3.44 mm. Elevated BMI is found to positively correlate with AMA and distance, indicating that higher BMI values may augment these parameters, with an additional positive correlation observed between AMA and distance. No significant correlations are found with patient age or sex. Conclusion: The study concludes that decreased BMI may pose a potential risk for SMA syndrome, as evidenced by the observed correlations with aortomesenteric parameters. Understanding these normal values in the Nepalese population is critical for accurate diagnoses and predictions using CT scans. The research highlights the impact of demographic factors on these parameters and emphasizes their significance in clinical assessments related to SMA syndrome.

Angiodysplasia simulating variceal bleeding: a challenging case report of diagnosis and intervention.

Introduction and importance: Angiodysplasia, a prevalent vascular anomaly in the gastrointestinal tract, often presents with upper gastrointestinal bleeding, sharing symptoms with gastric varices. The diagnostic challenge arises due to overlapping clinical features. This case report highlights the importance of considering angiodysplasia in the differential diagnosis, especially when variceal bleeding is less likely, and emphasizes the role of various diagnostic modalities in accurate identification. Case presentation: A 52-year-old male presented with severe hematemesis and melena, mimicking variceal bleeding. Despite initial management, bleeding persisted. Contrast-enhanced computed tomography revealed dilated vascular channels, raising suspicion for both gastric varices and angiodysplasia. Endoscopy confirmed an angiomatous lesion, inadvertently disrupted during the procedure, necessitating angiography. The angiographic findings supported the diagnosis of angiodysplasia, and successful interventions included temporary glue embolization and argon laser coagulation during endoscopy. The patient was discharged with stable hemoglobin; a 2-year follow-up showed no recurrence. Clinical discussion: The case discusses the challenges in differentiating angiodysplasia from varices, emphasizing the role of imaging and endoscopic modalities. It highlights the need for a tailored approach to treatment, including argon plasma coagulation, and underscores the significance of meticulous follow-up for recurrence. Conclusion: This case report elucidates the diagnostic and therapeutic journey in managing a patient with angiodysplasia masquerading as variceal bleeding. It emphasizes the importance of considering vascular anomalies without typical signs and the significance of individualized interventions for optimal patient outcomes. The 2-year follow-up without recurrence signifies the successful management of the case.

Anencephaly in a triplet pregnancy: Unprecedented spontaneous reabsorption in-utero and subsequent normal delivery via c-section: A rare case report.

Multiple pregnancies are infrequently encountered, with the incidence of spontaneous triplet pregnancies estimated at approximately 1 in 7000 pregnancies. Triplet gestations are recognized for their propensity to bring about a spectrum of pregnancy related complexities, encompassing fetal structural abnormalities, neurological anomalies, disturbances in amniotic fluid levels, preterm labor, and suboptimal neonatal outcomes. Anencephaly is a serious congenital defect where the brain and skull do not fully develop, often leading to a poor prognosis. It's a preventable neural tube defect (NTD) with timely intake of folic acid, is caused by the incomplete closure of the neural tube during fetal development, resulting in the absence of the cerebrum (responsible for thinking and coordination) and the front part of the brain (forebrain) in affected infants. While anencephaly in a triplet is scarcely reported, spontaneous reabsorption of an anencephalic fetus in utero is a rare and unexpected event, with no documented cases in triplet pregnancies until now. We report a case of anencephaly in a triplet pregnancy where the mother presented late during her third trimester, the reabsorption of the anencephalic fetus in utero is an unprecedented event, highlighting the unique nature of this triplet pregnancy.

Pericardial hydatid cyst: A comprehensive case report on diagnosis and multidisciplinary intervention in a young patient.

Pericardial hydatid cysts, although rare, present unique diagnostic challenges and require a multidisciplinary approach for effective management. This parasitic infection, caused by Echinococcus granulosus larvae, typically affects the liver and lungs but can manifest in the pericardium, leading to potentially life-threatening complications if untreated. The 22-year-old female's escalating dyspnea posed diagnostic challenges despite inconclusive echocardiography. Employing a multidisciplinary strategy, including preoperative albendazole therapy and surgical excision, effectively managed the condition. This case highlights the intricate diagnostic nature of pericardial hydatid cysts, emphasizing the importance of heightened clinical awareness, especially in endemic regions. The detailed clinical trajectory, imaging methodologies, and therapeutic interventions contribute significant insights to the medical community. The study aims to deepen comprehension and guide clinicians in refined diagnostic and treatment approaches for pericardial hydatid cysts, ultimately improving patient outcomes. It underscores the imperative for continued research in this niche to enhance medical understanding and optimize clinical practices.

Rare encounter: Adult-onset temporal lobe schizencephaly with septo-optic dysplasia - a case report on comprehensive diagnosis and management.

This case report presents a 21-year-old male with recurrent seizures attributed to isolated temporal lobe closed-lip schizencephaly coexisting with septo-optic dysplasia. Despite adult-onset seizures, the patient lacked motor deficits, maintaining normal developmental milestones. Comprehensive diagnostic modalities, including MRI revealing temporal lobe atrophy and associated abnormalities, contributed to the unique identification of schizencephaly. The classic triad of septo-optic dysplasia further complicated the clinical spectrum. Financial limitations influenced the predominantly conservative management, highlighting healthcare challenges. This case enhances our understanding of the rare congenital disorder, emphasizing the importance of tailored diagnostics and management strategies for diverse presentations of schizencephaly, particularly in the context of associated congenital anomalies.

Intracranial osteochondroma arising from the posterior clinoid process: a rare case report with diagnostic challenges and comprehensive literature review.

Introduction and importance: Intracranial osteochondroma is rare, presenting diagnostic challenges due to overlapping imaging findings with other pathologies. This case report highlights the significance of considering osteochondroma in calcified tumour differentials near bone. Case presentation: A 34-year-old man with vision deterioration and headaches had an MRI revealing a suprasellar lesion. Intraoperatively, a bony hard tumour was partially resected. Subsequent computed tomography (CT) confirmed a calcified mass contiguous with the posterior clinoid. Clinical discussion: Reviewing 28 cases, skull base osteochondromas were common, with differential diagnoses including craniopharyngioma and meningioma. Surgical decision-making involved balancing complete resection for convexity and falx cases versus partial resection for skull base tumours due to proximity to critical structures. Conclusion: Intracranial osteochondroma poses diagnostic challenges, especially near bone. Tailored surgical approaches are vital, with complete resection yielding good outcomes for convexity and falx cases. Close follow-up is crucial for monitoring recurrences and complications.

Lipoma arborescens in the dorsum of the hand: a case report and a comprehensive review.

Introduction and importance: Lipoma arborescens is a rare synovial disorder, typically affecting the knee joint, with limited reports of atypical presentations. The study emphasizes the need for a multidisciplinary diagnostic approach and discusses the genetic and signalling factors associated with its pathogenesis. Case presentation: A 50-year-old male presented with a painless swelling in the dorsum of the right hand, a rare extra-articular manifestation of Lipoma arborescens. Comprehensive clinical, imaging, and histopathological evaluations confirmed the diagnosis, revealing unique features on MRI and frond-like fatty tissue infiltration on excisional biopsy. Clinical discussion: The case underscores the distinct clinical characteristics, diagnostic challenges, and differential considerations associated with atypical Lipoma arborescens presentations. Extra-articular manifestation of Lipoma arborescens involving the dorsum (extensor aspect) of the hand is rare. Imaging techniques, including MRI and ultrasound, play a crucial role in accurate diagnosis, differentiating it from other joint pathologies. The MRI findings include intra-articular fat deposits and villous proliferation of the synovial membrane. At the same time, the histopathological analysis includes frond-like infiltration of sub-synovial tissue with mature adipocytes which helps in confirming the diagnosis. Conclusion: Successful surgical excision of the extra-articular lesion highlights the importance of a comprehensive diagnostic strategy for managing this uncommon condition. The study contributes valuable insights into understanding, diagnosing, and treating atypical presentations of lipoma arborescens.

Post-traumatic jejunal branch of superior mesenteric artery pseudoaneurysm in paediatrics: a compelling case report highlighting early diagnosis and successful endovascular embolization.

Introduction and importance: This manuscript underscores the critical significance of prompt diagnosis and intervention in cases of post-traumatic gastroduodenal artery pseudoaneurysms. Such occurrences, particularly in the paediatric population, are rare but potentially life-threatening complications following abdominal trauma, necessitating heightened clinical awareness. Despite their rarity, the devastating consequences of delayed recognition and management emphasize the necessity for advanced imaging modalities and individualized treatment strategies. Case presentation: A 17-year-old male presented with severe epigastric pain following a football fall. Despite initial stability, persistent symptoms prompted further investigation. Conventional screening methods proved inconclusive, leading to a contrast-enhanced computed tomography (CT) scan that revealed a jejunal branch of superior mesenteric artery (SMA) pseudoaneurysm. The subsequent fluoroscopy-guided angiography and successful embolization using glue exemplify the importance of timely intervention in such cases. Conclusion: This case highlights the importance of early recognition and appropriate intervention in post-traumatic jejunal branch of SMA pseudoaneurysms. The successful outcome achieved through endovascular embolization underscores the necessity for vigilant monitoring and tailored management strategies in similar clinical scenarios.

Endovascular embolization for massive hemoptysis in intralobar pulmonary sequestration with celiac artery supply: A comprehensive case report.

Pulmonary sequestration (PS) is a rare congenital anomaly characterized by noncommunicative lung tissue supplied by an abnormal systemic vessel. We present a case of a 30-year-old male with intralobar PS, receiving arterial supply from the celiac artery, manifesting as massive hemoptysis. After urgent stabilization, endovascular embolization using polyvinyl alcohol particles was successfully employed. The patient's symptoms resolved, and follow-up confirmed satisfactory recovery. Our case underscores the diverse arterial origins of PS and the efficacy of endovascular embolization as a minimally invasive treatment. The complexity of PS, its diagnostic imaging, and alternative therapeutic options are discussed, emphasizing tailored approaches for optimal outcomes in managing this uncommon congenital anomaly.

Tuberculous meningitis with stroke: A case report of diagnostic dilemma and therapeutic triumph.

Tuberculous Meningitis (TBM) is a rare manifestation of Mycobacterium tuberculosis infection affecting the meninges. We present a case of a 40-year-old male initially presenting with neurological deficits mimicking ischemic stroke. Despite classic signs, including fever, headache, and neck stiffness, TBM was initially overlooked, leading to delayed treatment. Comprehensive assessment, imaging findings, and characteristic cerebrospinal fluid findings, confirming TBM with tubercular stroke. The patient responded positively to antitubercular therapy and steroids. This case underscores the diagnostic challenges of TBM, emphasizing the need for a broad differential diagnosis, particularly in regions with a high tuberculosis prevalence. Recognition of atypical presentations is crucial for timely intervention and improved outcomes.

Benign pneumoperitoneum in a neonate receiving positive pressure ventilation: A case report and clinical insights.

The presence of air in the peritoneal cavity demonstrated radiographically as the crescent of air under the diaphragm is termed pneumoperitoneum. The causative agents may be divided into spontaneous, traumatic, iatrogenic, and miscellaneous. The majority (∼ 90%) of cases are attributed to hollow viscus perforation which requires immediate surgical attention. Neonatal pneumoperitoneum is a surgical emergency unless proven otherwise. A distinct entity termed benign pneumoperitoneum occurs in the absence of clinical and paraclinical features of peritonitis. Benign pneumoperitoneum may be caused by various thoracic, abdominal, and gynecological conditions. In neonates with respiratory distress pneumoperitoneum is a frequent association especially when treated with mechanical ventilation. The air leak phenomenon leads to air tracking from the ruptured alveoli along the interstitium to the mediastinum then to the retroperitoneum and ultimately into the peritoneal cavity. Such patients usually do not require surgical intervention and are managed conservatively. Knowledge of the existence of benign pneumoperitoneum helps to avoid unnecessary surgery thereby reducing operative morbidity and mortality.

Uncommon presentation of Rosai-Dorfman disease: Nasal and nasopharyngeal involvement: A case report and discussion.

This study presents a rare case of Rosai-Dorfman disease (RDD) with nasal and nasopharyngeal involvement, illustrating the complexities in diagnosing this enigmatic histiocytic disorder. RDD, characterized by massive, painless cervical lymphadenopathy, poses diagnostic challenges due to its diverse clinical presentations. In this case, a 38-year-old woman presented with a year-long history of neck swellings, nasal congestion, headaches, and sinusitis-like symptoms. Radiological imaging and histopathological examination revealed RDD involvement in the nasopharynx and paranasal sinuses. RDD diagnosis was confirmed through immunohistochemistry. The patient's unique symptoms emphasize the importance of considering RDD in the differential diagnosis of sinonasal masses with recurrent or unusual complaints. This case underscores the need for increased awareness, multidisciplinary management, and further research to enhance understanding and treatment of RDD, especially in extranodal presentations.

Diagnostic journey and multimodal management of a rare urogenital rhabdomyosarcoma with rectovaginal fistula in an adolescent: a case report.

Introduction and importance: Rhabdomyosarcoma is a malignant tumour that originates from immature muscle cells and belongs to the category of soft-tissue sarcomas. It is predominantly diagnosed in children under the age of 6. This condition can manifest within the genitourinary tract and may exhibit non-specific symptoms such as changes in bowel habits and fever. Early detection and a comprehensive, multidisciplinary approach are essential to achieving more favourable outcomes. This report highlights an uncommon case of urogenital rhabdomyosarcoma in a 15-year-old girl, in addition to the presence of a rectovaginal fistula. Case presentation: A 15-year-old girl with presented with fever, altered bowel habits, and a lump in her lower abdomen, abdominal discomfort, and incomplete bowel evacuation. She also had faecal discharge from the vagina. Diagnostic imaging and biopsy confirmed urogenital rhabdomyosarcoma with a rectovaginal fistula. The patient is currently undergoing induction chemotherapy and is scheduled for radiation therapy and surgery. Clinical discussion: Rhabdomyosarcoma is a rare paediatric oncologic concern due to its aggressive nature and potential metastasis. The presentation varies based on age, tumour location, and metastasis presence. This patient presented with altered bowel habits, a pelvic mass and unusual feculent discharge, suggesting a rectovaginal fistula. Diagnostic imaging confirmed the diagnosis, and induction chemotherapy led to a positive response and reduced tumour size. Conclusion: Urogenital rhabdomyosarcoma is an aggressive malignancy with non-specific symptoms, making early diagnosis challenging. An accurate diagnosis requires high suspicion, imaging, and a biopsy. Multidisciplinary management, including surgery, chemotherapy, and radiation therapy, improves outcomes and improves paediatric patients' prognosis and quality of life.

Comparative analysis of automated breast volume scanner (ABVS) combined with conventional hand-held ultrasound and mammography in female breast cancer detection.

Objective and background: This study aimed to compare the diagnostic value of an automated breast volume scanner (ABVS) combined with conventional hand-held ultrasound and mammography in detecting female breast cancer. Early detection is vital in improving patient outcomes for this prevalent disease. Methods: Seventy-eight suspicious breast lesions from 60 patients were examined between August 2019 and July 2020. Each patient underwent ABVS, conventional hand-held ultrasound, and mammography. Diagnostic values, including coincidence rate, sensitivity, specificity, positive predictive value, and negative predictive value, were calculated using histopathology results as the "gold standard." Results: Histopathology confirmed 55 malignant (70.51%) and 23 benign lesions (29.48%). ABVS combined with conventional hand-held ultrasound identified 56 malignant (52 confirmed, 4 benign) and 22 benign nodules (3 confirmed, 19 benign). Mammography detected 48 malignant (45 confirmed, 3 benign) and 30 benign nodules (10 confirmed, 20 benign). ABVS combined with conventional hand-held ultrasound had a sensitivity of 94.5%, specificity of 82.6%, positive predictive value of 92.9%, and negative predictive value of 86.4%. Mammography showed a sensitivity of 81.8%, specificity of 87.0%, positive predictive value of 93.8%, and negative predictive value of 66.7%. Conclusion: ABVS combined with conventional hand-held ultrasound showed high diagnostic value in detecting female breast cancer. The "convergence sign" in the coronal section played a significant role. It slightly outperformed mammography and offered advantages in terms of cost, convenience, comfort, and absence of radiation. Further promotion and implementation are supported.

Chronic multifocal tubercular osteomyelitis in a young Nepalese boy: A rare case presentation.

This study presents a rare case of chronic multifocal tubercular osteomyelitis in a 13-year-old boy from Nepal, a high-burden country for tuberculosis (TB). He presented with chronic pain in the lower extremities and had no pre-existing comorbidities. The patient's clinical presentation, diagnostic process, and treatment plan are described. Multifocal skeletal TB, though infrequent, poses diagnostic challenges due to its variable manifestations. This case emphasizes the importance of considering TB in differential diagnoses, especially in endemic regions, necessitating a high index of suspicion. Early detection and treatment align with WHO's "End TB" strategy and Nepal's TB management guidelines, promoting improved outcomes in high-risk populations.

Left-sided acute appendicitis in a patient with situs inversus totalis: A case report and a comprehensive review.

AA is a frequent surgical condition that demands urgent intervention. It accounts for approximately 6% of all emergency department visits. Situs inversus is a rare condition in which the orientation of asymmetric organs is a mirror image of normal anatomy. It can be partial (involving either the abdominal or thoracic cavities) or complete (situs inversus totalis: transposition of both abdominal and thoracic organs). SIT is very rare, with an incidence of 1 per 5000 to 10,000 live births. It is inherited in an autosomal recessive pattern with incomplete penetrance. LSAA is very rare and can happen in association with other congenital abnormalities such as situs inversus, midgut malrotation (MM), or a usually long right-sided appendix projecting into the left lower quadrant. SIT is responsible for greater than 67% of left-sided appendicitis cases. Due to atypical clinical presentation, the diagnosis of AA can be difficult and often delayed. Hence, a complete medical history, physical examination, laboratory tests, and imaging tools are necessary to reach a correct diagnosis in a timely manner and prevent complications like abscesses, perforations, and peritonitis. We report a case of a 50-year-old male with symptoms of left lower abdominal pain along with fever, nausea, vomiting, and loose stools that were later diagnosed as LSAA in the setting of SIT.

Malignant rectal GIST managed with chemotherapy (Imatinib Mesylate): A case report and a comprehensive review.

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors involving the gastrointestinal tract, arising from the interstitial cells of Cajal. GIST comprises about 1% of all GI tumors. Rectal GISTs are rare and comprise of approximately 5% of all GISTs and only 0.1% of rectal tumors are found to be GISTs. Rectal GISTs may be diagnosed incidentally or present with symptoms, including defecation problems, bleeding, and/or pain. We report a case of a 46-year-old male with rectal GIST metastasized to the liver and bilateral lung parenchyma managed by Imatinib Mesylate (IM) regimen. Rectal GIST although being rare, must be considered as a differential diagnosis in a patient presenting with defecatory problems with bleeding.

Measurement of portal vein indices and splenic index by ultrasound and their association with gastroesophageal varices in cirrhosis of liver.

Background and Objectives: Esophageal and gastric fundic varices are common in liver cirrhosis patients. Ultrasound with the Doppler study assesses liver cirrhosis severity, measuring portal vein and splenic indices' association with gastroesophageal varices. Methodology: This study was conducted on 64 subjects with sonographic features of chronic liver disease who were referred for routine follow-up scans. Portal vein diameter, average velocity, splenic index, congestion index (CI), and portal vein area and velocity were measured. Result: Subjects with gastroesophageal varices had significantly larger portal vein diameters (14.7±1.64 mm) compared to those without varices (12.05±1.26 mm) (P<0.05). Conversely, subjects without varices exhibited a higher portal vein velocity of (17.9±0.6 cm/s) than with varices (13.91±2.01 cm/s) (P=0.0005). The splenic index was higher in subjects with varices (1120±494 cm3) than those without varices (419 cm3) (P<0.05). The CI was also higher in subjects with varices. Portal vein velocity showed the highest sensitivity (94%) with a cutoff of 19 cm/s, while the CI had the highest diagnostic accuracy (93.75%) with a cutoff of 0.10 cm xsec. The splenic index demonstrated a sensitivity of 92.85% and diagnostic accuracy of 92.18% with a cutoff of 480 cm3. The splenic index followed by the CI is found to be a better predictor of esophageal varices (area under the curve of 96.8 and 96%, respectively). Conclusion: Ultrasonographic assessment of the portal vein and spleen is a reliable, noninvasive method for predicting gastroesophageal varices in liver cirrhosis. The splenic index and CI have high diagnostic accuracy.

Computed tomographic assessment of risk of anterior skull base injury of adult patients in tertiary care centre: a cross-sectional study.

Background and objectives: Functional endoscopic sinus surgery (FESS) carries the risk of anterior skull base injury. Understanding computed tomography of the paranasal sinuses (CT PNS) and anatomical variations is crucial before surgery. Several classifications, including Kero's, Gera's, and Thailand-Malaysia-Singapore (TMS), assess the risk of skull base injury. The objective was to determine the risk of anterior skull base injury using CT PNS in adult patients. Methods: A study of 188 patients with head and paranasal sinus pathologies used CT scans to measure olfactory fossa depth, the angle between lamina papyracea and horizontal plane, and the distance from the orbital rim to the cribriform plate. Variations were classified using Kero's, Gera's, and TMS classifications. Results: The study involved 188 individuals aged 18-85, with OF depths ranging from 0.1 to 0.52 cm. Kero's Class I was observed in 82.44% and 81.38% of individuals, while distances from orbital floor to cribriform plate and ethmoidal roof ranged from 1.37 to 2.93 cm. TMS Type I was observed in all individuals, and the angle between lateral lamella of the cribriform plate and cribriform plate ranged from 34° to 85°. Gera's Class II was observed in 77.12% and 84.57% of individuals. Conclusion: CT PNS provides important anatomical information for assessing the risk of skull base injury during FESS. Kero's, Gera's, and TMS classifications can be utilized to evaluate this risk. The study findings provide insights into the variations in olfactory fossa depth, distance measurements, and angle, which can aid in preoperative planning and reducing complications during FESS in Nepalese populations.

Uncommon presentation: isolated small bowel perforation after blunt abdominal trauma in a pediatric patient; a case report.

Introduction and importance: A small bowel perforation occurring in isolation as a result of blunt abdominal trauma (BAT) is a rare event, especially in pediatric patients. The unusual presentation and lack of distinct clinical indications can pose a challenge in promptly diagnosing this condition. This study seeks to underscore the importance of early detection and immediate surgical intervention when dealing with small bowel perforations following BAT. Case presentation: A 13-year-old girl arrived at the emergency department after falling from a cliff. Initial evaluations, including a physical examination and imaging studies, did not uncover any notable irregularities. Nevertheless, the persistent abdominal discomfort and pain prompted further concerns. A contrast-enhanced computed tomography scan was performed, confirming ileal perforation. The patient subsequently underwent exploratory laparotomy, which resulted in successful surgical treatment. Clinical discussion: BAT causes increased intraluminal pressure, leading to blowout perforation of the small bowel. Diagnosis can be challenging, particularly in the absence of immediate symptoms or conclusive radiographic findings. Close observation and repeated examinations are essential to detect delayed perforations. Early surgical intervention within 12 h of injury has been shown to significantly reduce complications and mortality rates. Conclusion: Isolated small bowel perforation is a rare occurrence in pediatric patients, and timely diagnosis and surgical intervention are crucial for favorable outcomes. Diagnostic imaging, like contrast-enhanced computerized tomography, helps identify the condition when clinical findings are inconclusive. Comprehensive counseling is essential for patients and their families to understand potential risks and intervention needs, ensuring appropriate management, and treatment delays.