Revisiting the forgotten remnant: Imaging spectrum of Meckel's diverticulum.

Meckel's diverticulum is a true diverticulum of the alimentary tract occurring resulting from the persistence of remnants of the vitello-intestinal duct. They are often asymptomatic and incidentally diagnosed during surgery. Complications such as intestinal obstruction, diverticulitis, intestinal haemorrhage and perforation may occur with Meckel's diverticulum, which renders them symptomatic. The clinical and imaging diagnosis of Meckel's diverticulum is very challenging. As a result of the rare occurrence of complicated Meckel's diverticulum and the difficult preoperative diagnosis, knowledge of its imaging features is limited. The presented case series describes a spectrum of complications caused by Meckel's diverticulum and its CT imaging features. It highlights the importance of a high clinical suspicion by carefully searching for a Meckel's diverticulum on CT in its characteristic location to avoid missing it preoperatively.

Inverted Meckel's diverticulum: a case report.

BACKGROUND: Inverted Meckel's diverticulum refers to the condition in which the diverticulum inverts on itself. The reasons for such an inversion are poorly understood due to the rarity of the condition. We present a case of inverted Meckel's diverticulum, an uncommon finding, as a cause of recurrent intussusception. CASE PRESENTATION: A 30-year old Indian woman presented with complaints of pain in the central abdomen for 3 days, accompanied with vomiting and loose stools. Computed tomography images were suggestive of intussusception with intestinal obstruction. Intra-operative findings were suggestive of an intussuscepted segment of ileum measuring 10 cm in length, proximal to ileocecal junction. Ileo-ileal anastomosis was performed after appropriate resection. Upon opening the specimen, we were surprised to find an inverted Meckel diverticulum with lipoma at one end causing the intussusception. The patient made an uneventful recovery and was discharged after 5 days. CONCLUSION: The reasons for inversion include abnormal peristalsis around the diverticulum and non-fixity of the diverticulum itself. The inverted diverticulum itself can cause luminal compromise and acts as a lead point for intussusception leading to obstruction. Computed tomography remains the diagnostic tool of choice for identifying intestinal obstruction and intussusception. Although pathological signs, such as lipoma, can be identified, the identification of any inversion will require a proficient radiologist. Inverted Meckel's diverticulum is a rare condition which is difficult to diagnose preoperatively. Treatment is surgical, whether diagnosed pre-operatively or intra-operatively, and includes segmental resection and anastomosis. This uncommon condition should be noted as one-off differential diagnosis for intussusception and intestinal obstruction.

Pre-sternal thyroid swellings: a case of rare aberrant site recurrence and review of literature.

BACKGROUND: Thyroid swellings enlarge caudally into the mediastinum behind the sternum. Pre-sternal swelling of thyroid origin is very rare. We present our case of pre-sternal thyroid swelling which was albeit a surprisingly rare site of papillary thyroid carcinoma recurrence and review of pre-sternal thyroid swellings reported till date. CASE SUMMARY: A 60 year old female presented with a painless, progressive swelling on the anterior part of the chest for the past 2 years. A 15 cm × 8 cm vertically aligned, non tender, well defined swelling was present on the pre-sternal region, with consistency ranging from soft to firm. The swelling was fixed to the underlying tissues and a fixed level IV lymph node was palpable on the right side. Ultrasonography revealed a large mass of 15 × 7 cm with multiple cystic areas. Fine needle aspiration cytology was inconclusive twice. Patient had undergone a total thyroidectomy for papillary carcinoma 10 years back. Computed tomography findings revealed a large 15 × 6.6 × 7 cm lobulated, pre-sternal, soft tissue lesion with solid & cystic components. The mass was infiltrating the right sided strap muscles and sternocleidomastoid. FNAC was inconclusive and thyroid scan could not pick up any activity in the mass. Henceforth a PET scan was done that showed increased FDG uptake by the lesion and the level IV lymph node. The patient underwent wide excision of the mass with right functional neck dissection, along with removal with both sternal head of sternocleido-mastoid, the strap muscles and the surrounding fascia. Histopathology confirmed papillary thyroid carcinoma. Patient received post-operative radioactive iodine ablation and is healthy with no recurrence up to 30 months of follow up. DISCUSSION: The mechanisms for pre-sternal thyroid swelling are not understood due to paucity of cases. The mechanisms proposed are invasion of strap muscles and cervical linea alba and tumor cells spread anterior to sternum, truly ectopic thyroid tissue, de novo carcinogenesis in the embryonal remnants like the thyro-thymic residues, sequestered thyroid tissue which grows later or migration of thyroid cells, incomplete clearance at the time of primary surgery or intraoperative seeding. CONCLUSION: Pre-sternal region masses of thyroid origin are very rare. A proper work up, suspicion for thyroid mass and array of tests will be required to come to a provisional diagnosis. Since the masses reported in literature were primarily malignant, any such mass may be treated on lines of malignancy with radical surgery.

Malrotation of the Gut in Adults: An Often Forgotten Entity.

Malrotation of the gut is a common paediatric condition that usually presents in the first month of life. However, presentation in adults is rare, and as a diagnostic dilemma quite often surprises the surgeon intraoperatively. If this condition is not timely recognized, it may result in disastrous consequences, such as gangrene of the small gut. We present the case of a 21-year-old male who presented to the emergency room with recurrent episodes of colicky abdominal pain and bilious vomiting. Contrast-enhanced computerized tomography (CT) revealed malrotation of the gut. The patient was planned for Ladd's procedure. Malrotation in adults may present in an acute way due to midgut volvulus or may have a chronic indolent course with recurrent vomiting and abdominal pain. In patients with acute obstruction, this differential should be kept in mind, especially if the patient has no previous abdominal surgery or evidence of tuberculosis. Contrast-enhanced CT is the investigation of choice and reveals typical findings, like whirlpool sign, corkscrew sign, or reversed relation of superior mesenteric artery and vein. The treatment is surgical as failure to do so may result in intestinal gangrene. The procedure of choice is Ladd's procedure. Every patient, even if asymptomatic, warrants this procedure as it is impossible to predict the timing of catastrophic complications.

Prevalence of abuse in mentally ill patients visiting outpatient setting in a tertiary care hospital in India.

AIM: In a developing country such as India, the abuse of patients suffering from psychiatric disorders has been underreported. The aim of this study was to detect abuse in chronically ill psychiatric patients visiting a psychiatric outpatient setting in a tertiary care hospital in Delhi, India. MATERIAL AND METHODS: A cross-sectional descriptive written survey was carried out on 406 patients. A self-administered questionnaire for patient abuse was developed in Hindi based on the World Health Organization's Domestic Violence Questionnaire that encompassed questions regarding physical, emotional and sexual abuse. RESULTS: Of the 406 patients, 294 (72%) suffered from abuse, with 64% experiencing emotional abuse, 39% physical abuse and 21% sexual abuse. In chronically ill psychiatric patients, a significant association was found between education and abuse, with most abuse occurring among senior secondary pass outs (i.e. 11-12 years of education) and least among junior high school pass outs (6-8 years of education). A majority (74%) of these patients lived in urban areas (p = .020). A significant association was also found between abuse and the psychiatric diagnosis of the patient, with 53% suffering from depression, 66% anxiety disorder, 81% bipolar disorder, 94% psychotic disorder, 86% obsessive compulsive disorder, 44% sexual disorder and 12% other psychiatric disorders. CONCLUSIONS: There is a need to create awareness in society in order to prevent abuse. Screening for abuse in routine psychiatric practice is of utmost importance so that timely interventions can be given, thereby preventing its deleterious health consequences.