Hepatitis A virus induced acute acalculous cholecystitis diagnosed postoperatively: Case report.

INTRODUCTION: acute acalculous cholecystitis (AAC) is defined as gallbladder inflammation without the presence of stones. Contrary, hepatitis A virus (HAV) can present with different symptoms; however, HAV causing and presenting as AAC is rare. CASE PRESENTATION: 41-year-old previously healthy patient presented with right upper quadrant abdominal pain. The pain was persistent and associated with vomiting and laboratory tests showed elevated bilirubin. Laparoscopic cholecystectomy showed inflamed gallbladder with no stones and intraoperative cholangiography showed no abnormalities. Day one post-operation, while the pain resolved, labs showed elevated liver function tests and hepatitis workup showed acute HAV infection attributing her presentation to HAV induced AAC. DISCUSSION: AAC is usually caused by stasis of the gallbladder due to different causes; however, HAV induced AAC has been rarely reported. While cholecystectomy is the mainstay treatment for AAC, this might not be the case for HAV induced AAC. For instance, unless there is necrotic gallbladder or persistence of symptoms, AAC can be managed conservatively in this case. Even though our diagnosis was cleared post-operatively, had we knew the diagnosis of HAV induced AAC before, we would have still opt for surgery due to the severity and persistence of pain. CONCLUSION: More cases should be reported and more studies should be done to further define the presentation and management of HAV induced AAC.

Primary Hepatic Neuroendocrine Tumor: A Case Report and Literature Review.

Primary hepatic neuroendocrine tumors (PHNETs) are extremely rare and account for about 0.3% of all neuroendocrine tumor cases. Resection is usually difficult because they are usually diagnosed in the late stages. We report the case of a patient diagnosed with PHNETs, initially classified as unresectable but then underwent a successful left hepatectomy. PHNETs are rare malignant tumors, and a high index of suspicion is warranted for the diagnosis after excluding the presence of a primary extrahepatic lesion. Radical hepatectomy can be curative when feasible along with a combination of multiple treatments that improve the prognosis.

Meckel's Diverticulum Causing a Small Bowel Obstruction in an 80-Year-Old Male: Report of a Rare Case and Review of the Literature.

Meckel's diverticulum (MD) is the most common congenital malformation occurring in the gastrointestinal tract and results from the persistence of the vitelline duct during embryology. MD is typically asymptomatic in adults with most of its symptoms manifesting in early childhood. Small bowel obstruction (SBO) due to MD in the elderly population is an entity that has not been widely described in the literature. We present a very rare case of SBO in an 80-year-old patient with no previous abdominal surgeries (virgin abdomen). The cause of obstruction was determined to be an adhesive band formed on top of an MD. The obstruction was relieved and the small bowel segment that contained the diverticulum was resected, and anastomosis was made.

Gastric Volvulus: A Delayed Surgical Complication After Debulking and Hyperthermic Intraperitoneal Chemotherapy for Advanced Ovarian Cancer.

Gastric volvulus in conjunction with diaphragmatic hernia is an uncommon but life-threatening presentation that is generally in association with hiatal hernia or diaphragmatic injuries. Diaphragmatic hernia with gastric volvulus can occur many years after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy despite initial diaphragm intactness, and should be suspected in this patient population when they present with upper gastrointestinal obstruction. An acute episode of gastric volvulus can have a mortality of 30% to 50%, hence the importance of early diagnosis and treatment. Surgical management remains the treatment of choice and can be an emergency in obstructive cases. We report the case of a 68-year-old woman presenting with signs and symptoms of acute upper gastrointestinal obstruction. Three years ago, the patient had undergone debulking surgery and hyperthermic intraperitoneal chemotherapy for peritoneal carcinomatosis secondary to advanced ovarian cancer. A diagnosis of gastric volvulus was established. The pylorus was seen near the cardia on gastroscopy, and barium swallow showed stomach upside down and with a mirror image of normal anatomy suggestive of gastric volvulus. We opted for urgent laparotomy that revealed the presence of a rotated stomach adherent to the spleen and left diaphragm. After reduction, a diaphragmatic defect that was missed on the computed tomography scan was discovered and repaired, and the patient recovered uneventfully.

Symptomatic Pneumomediastinum Following Laparoscopic Cholecystectomy: A Case Report and a Literature Review.

Isolated pneumomediastinum is a rare complication after laparoscopic procedures. Herein, we present a case of a 38-year-old woman who presented two days after laparoscopic cholecystectomy with pleuritic chest pain and dyspnea and was found to have isolated pneumomediastinum. The patient was admitted for monitoring, oxygen therapy, and antibiotic prophylaxis and she was discharged on the fourth postoperative day when her symptoms resolved both subjectively and radiologically. Only two other cases of symptomatic isolated pneumomediastinum after laparoscopic cholecystectomy were reported in the literature and all of them were female patients, diagnosed radiologically, and treated conservatively. Therefore, isolated pneumomediastinum should be included in the differential diagnosis of dyspnea and chest pain after laparoscopic surgeries in order to have an early diagnosis, start early treatment, and prevent unnecessary investigations or advancement of the disease.

Spontaneous Gastric Intramural Hematoma: Case Report and Literature Review.

Spontaneous gastric intramural hematoma is a rare disease. Herein, we present a case of a previously healthy 28-year-old male patient who presented with diarrhea and diffuse abdominal pain of one-week duration. The patient was diagnosed with spontaneous gastric intramural hematoma post urgent partial gastrectomy for a bleeding gastric tumor. Six other cases of spontaneous gastric intramural hematoma are published in the literature; therefore, when encountering a case of intra-abdominal mass attached to the gastric wall, gastric intramural hematoma should be considered in the differential even when no cause is present.

Surgical management of 10 years delayed recurrent acute pancreatitis post Whipple procedure for chronic pancreatitis: A case report.

INTRODUCTION: In patients who underwent pancreatoduodenectomy for management of Chronic pancreatitis, early and late anastomotic failure can occur [1]. Nevertheless, taking into consideration that most pancreatic head resections are performed for malignant disease with poor prognosis, long term pancreatico-jejunal anastomotic durability has not been well examined; similarly, the management of its stenosis has not been well assessed [1]. CASE: Here we present a case of a 69 years old male patient with history of chronic alcoholic pancreatitis and ampullary fibrosis managed by pancreatico-duodenectomy presenting for 10 years delayed onset of recurrent acute pancreatitis with signs of pancreatico-jejunal anastomotic stenosis, managed surgically with revision of pancreatico-jejunal anastomosis. CONCLUSION: Our case report might hold strongly for bringing up a purposeful approach, and be an insight to take into consideration in approaching pancreatic anastomosis, especially when pancreatic resections are utilized for treating benign pathologies.

A non-klatskin tumor: A case report and review of intrabiliary hydatid cyst rupture.

INTRODUCTION: A 64-year-old lady was diagnosed with having a klatskin type 3A tumor based on imaging, however, an alternative diagnosis was achieved during surgery. PRESENTATION OF CASE: We present a case of a 64-year-old lady who presented for new-onset jaundice and was diagnosed with type 3A klatskin tumor based on MRCP findings. During surgery, it was revealed that the obstruction was caused by a frank intrabiliary hydatid cyst perforation. Choledocoscopy with irrigation, cholangiography, and removal of the mother cyst were performed, and an end-to-end biliary anastomosis over a t-tube was then done. The patient tolerated the intervention and recovered well. DISCUSSION: Hydatid cyst disease of the liver usually follows a benign course, however, intrabiliary rupture is one of the common complications associated with this disease. Intrabiliary rupture is classified into either frank or occult. Frank perforation, which is more common, is when hydatid material passes into the biliary ducts, and it may cause biliary obstruction and cholangitis with a high mortality rate. Occult perforation is when the hydatid cyst becomes infected itself, which usually leads to a silent presentation, and may only cause signs of suppuration. Diagnosis is usually achieved by imaging and relevant history. Treatment consists of medical and surgical intervention. Intraoperative cholangiography, choledocoscopy, and t-tube drainage are recommended during surgery for frank rupture. CONCLUSION: Intrabiliary hydatid cyst perforation can mimic cholangiocarcinoma and must be considered as an alternative diagnosis in these patients prior to surgery.

Splenoptosis in young female, case report.

BACKGROUND: Splenoptosis is an uncommon disorder defined as the dislodgment of the spleen from its anatomical location in the left hypochondrium to another location in the intraabdominal cavity. This migration is the result of laxity or absence of the ligaments that fix the spleen to surrounding structures. Splenoptosis is either diagnosed after it causes symptoms, or incidentally using different imaging modalities. Surgery is the definite treatment either by splenopexy or splenectomy. CASE PRESENTATION: In the case presented here, we discuss a 17 years old female patient who presented to our institution for acute onset of abdominal pain, mainly suprapubic, occurring for 4 days. Ultrasound showed a suspicious right pelvic mass, which was found to be a wandering spleen with pedicle torsion. The patient was treated surgically by splenectomy. CONCLUSION: We report this rare case to encourage physicians to keep this etiology in mind as part of the differential diagnosis of unspecific abdominal pain.

A Rare Case of a Ruptured Metastatic Hepatic Lesion from a Jejunal Gastrointestinal Stromal Tumor (GIST) Treated by Arterial Embolization.

BACKGROUND Gastrointestinal stromal tumors (GISTs) are rare gastrointestinal neoplasms. The spontaneous rupture of a jejunal GIST is very rare and spontaneous rupture of liver metastasis from an intestinal GIST is even rarer with only a few cases reported in the literature. CASE REPORT In this article, we reported a case of spontaneous rupture of a liver metastasis from a malignant jejunal GIST that presented with active tumoral bleeding, hypovolemic shock, and hemoperitoneum. The patient was successfully treated with arterial embolization of the tumor. CONCLUSIONS In appropriately selected patients, arterial embolization appears to be an effective safe treatment for a GIST metastasis rupture.

Weight Regain After Sleeve Gastrectomy: A Look at the Benefits of Re-sleeve.

Introduction Laparoscopic sleeve gastrectomy (LSG) has become one of the most commonly performed weight loss procedures due to its simpler technique and lower complication rate as compared to the Roux-en-Y gastric bypass and duodenal switch. However, weight regain is seen in patients with a large gastric fundus. In these cases, a revision laparoscopic sleeve gastrectomy (reLSG) aiming at resecting the excess pouch is a promising option for correction. Methods From April 2013 to March 2016, six patients underwent a reLSG for a failure of weight loss after the demonstration of a large gastric fundus on the upper gastrointestinal (UGI) series. Results One patient out of six (16.7%) suffered from a gastric leak and was lost to subsequent follow-up. The rest (83.3%) had a smooth recovery and were followed up for a mean of 18 months. Mean excess weight loss (EWL) was 68%, with a minimum of 48% and a maximum of 75%. Conclusion reLSG is a promising option for failed weight loss after LSG in patients who demonstrate the presence of a large gastric pouch. It carries a higher complication rate than the initial procedure. Further trials and meta-analyses are needed to prove the efficacy of this procedure.

Periampullary Neuroendocrine Tumor as a Cause of Acute Pancreatitis.

BACKGROUND Duodenal and ampullary carcinoids are very rare tumors accounting respectively for 2% and 0.03% of all carcinoid tumors. Clinical findings vary according to the location of the tumor within the periampullary region; with epigastric pain being the most common presenting symptom in duodenal carcinoids and jaundice the most common clinical finding in ampullary carcinoids. Treatment options include pancreaticoduodenectomy, local excision, and endoscopic excision. CASE REPORT In this case report, we present a 60-year-old male who presented with a one-week history of intractable epigastric pain. He was diagnosed with duodenal periampullary carcinoid tumor and treated with local excision. CONCLUSIONS Although duodenal and ampullary carcinoid tumors may have different clinical presentations, as well as histochemistry characteristics and metastatic potential, they appear to benefit from the same surgical treatment.

Diagnosis and Treatment of Small Bowel Strangulation Due To Congenital Band: Three Cases of Congenital Band in Adults Lacking a History of Trauma or Surgery.

BACKGROUND Among the causes of constipation are bands and adhesions that lead to obstructions at different points in the intestinal tract. These can occur as a consequence of healing following surgery or trauma. However, an entity known as congenital band exists where a band is present from birth. Here we report three such cases of adults with symptoms of intestinal obstruction, in whom a congenital band was discovered through exploratory laparoscopy. CASE REPORT All three of these patients presented lacking a history of any abdominal trauma or previous abdominal surgeries, a fact that is often used to exclude an adhesion as a differential. All three recovered quickly and had relief of their symptoms following surgical intervention. CONCLUSIONS Bands and adhesions are common surgical causes of small bowel obstruction, leading to symptoms such as nausea, vomiting, constipation, and obstipation. These bands almost always result from a prior abdominal surgery or from a recent abdominal trauma. The three cases presented here show a far more unusual picture of a band, one that is congenitally present, as there was an absence of such a history. This is significant because clinical suspicion of a band is often very low due to a lack of distinguishing clinical and diagnostic features, and when the past history is negative.

Incidental Finding and Management of Mesenteric Fibromatosis.

BACKGROUND: Mesenteric fibromatosis, also known as mesenteric desmoids, is part of the clinical-pathologic spectrum of deep fibromatosis, which encompasses a group of benign fibro-proliferative processes that are locally aggressive and have the capacity to infiltrate or recur without metastasis. CASE REPORT: Case of a 45-year-old man, with a history of hypertension and lung fibrosis, presenting for a left abdominal mass, which was found incidentally during his lung fibrosis imaging. He complained of constipation due to pressure upon his bowel leading to difficulty in defecation. CONCLUSIONS: Although there are many overlapping criteria between gastrointestinal stromal tumors and mesenteric fibromatosis, making it difficult to discriminate between the two, there are differences that are unique to mesenteric fibromatosis that should be noticed during the diagnosis. In this case, mesenteric fibromatosis was unusual as it is not associated with Gardner's syndrome, desmoid tumors, nor familial adenomatous polyposis, but was an incidental finding.

The early use of Roux limb as surgical treatment for proximal postsleeve gastrectomy leaks.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) is thought to be a simpler and safer operation compared with malabsorptive operations that include an enteric anastomosis. Leakage along the staple line at the gastroesophageal junction (GEJ) is difficult to treat and is a known complication of sleeve gastrectomy. Nonsurgical treatment methods often fail to heal the leaks and patients often require conversion to other procedures for definitive treatment. We report our experience with conversion to Roux-en-Y anastomosis over the leak site as a treatment option, comparing patients who had early treatment to late intervention. The purpose of the study is to stress the medical and social benefits of early surgical reintervention with conversion to Roux-en-Y anastomosis over the leak site. METHODS: Six patients underwent Roux limb placement over the leak site. Four of the patients had delayed surgery (group A), and the other 2 had early intervention (group B). RESULTS: Patients in group A had a median increase of all medical cost by 500%, whereas the 2 patients who underwent early intervention (group B) had an increase by 200%. The mean time until complete recovery (removal of all drains, adequate oral intake, and return to normal daily activity) in group A was 131.25 days (range 99-165) versus 38 days (range 28-48) in group B. CONCLUSIONS: Roux-en-Y gastrojejunostomy over the leak site is an effective technique to treat refractory staple line leakage and can be adopted as early treatment in selected patients after stabilization, thereby reducing the cost and length of hospital stays.