Rare presentations of small bowel endometriosis.

Despite endometriosis being a relatively common chronic gynecological condition in women of childbearing age, small bowel endometriosis is rare. Presentations can vary from completely asymptomatic to reported symptoms of abdominal pain, bloating, and diarrhea. The following two cases depict very atypical manifestations of ileal endometriosis that presented as obscure intermittent gastrointestinal bleeding and bowel obstruction requiring surgical intervention. The first case describes a previously healthy 40-year-old woman with severe symptomatic iron deficiency anemia and intermittent melena. A small bowel enteroscopy diagnosed multiple ulcerated strictures in the distal small bowel as the likely culprit. Despite nonsteroidal anti-inflammatory drug-induced enteropathy being initially considered as the likely etiology, histopathological examination of the resected distal ileal segment revealed evidence of endometriosis. The second case describes a 66-year-old with a presumptive diagnosis of Crohn's disease who reported a 10-year history of intermittent perimenstrual abdominal pain, diarrhea, and nausea with vomiting. Following two subsequent episodes of acute bowel obstruction and surgical resection of the patient's stricturing terminal ileal disease, histopathological examination demonstrated active chronic inflammation with endometriosis. Small bowel endometriosis should be considered as an unusual differential diagnosis in women who may present with obscure gastrointestinal bleeding from the small bowel or recurrent bowel obstruction.

Osteonecrosis of the Jaws: An Update and Review of Literature.

Aim: To provide a concise review on risk factors, stages, pathophysiology, prevention and possible treatment options for both MRONJ and ORN individually. Methods: The review was conducted according to the 'Preferred Reporting Items for Systematic Reviews and Meta-Analyses' (PRISMA) guidelines. A comprehensive search of the PUBMED, Ebsco, SCOPUS, WEB OF SCIENCE and NDH for articles published up until 2021 was performed. After screening and full text analyses, 44 studies were included in this review. Definition, risk factors, etiology, symptoms, stages, pathophysiology, prevention and possible management options were explored and highlighted in this article. Results: Three studies described osteonecrosis of jaw (ONJ) in general, 15 studies described ONJ associated with radiotherapy and 26 studies described ONJ associated with medications. Both the two conditions (ORN) and (MRONJ) have relatively similar clinical presentations clearing the fact that a resemblance in clinical presentations does not necessarily denote a similar pathophysiology. Conclusion: However, various advancements have been made in the control and management of ONJ, but until and unless need for high tumoricidal doses exists, ONJ will certainly continue to remain as a clinical challenge demanding satisfactory treatment to improve the quality of life of the patient.

Carcinoid tumours of the appendix: an analysis of emergency appendicectomies over a 24-year period and outcomes of laparoscopic versus open resection.

BACKGROUND: Carcinoid tumours of the appendix are the most common primary malignant lesion of the appendix. However, the overall incidence remains low; found in as few as 0.3-0.9% appendicectomy specimens. Almost all appendiceal carcinoids are found incidentally during surgery for suspected appendicitis. METHODS: A retrospective review of all appendiceal carcinoids was performed in six hospitals from January 1990 until December 2013. Demographic data, operative technique, histopathological characteristics, clinic reviews and need for further treatment were recorded and compared with literature. RESULTS: Appendiceal carcinoids were identified in 175 specimens. The mean age is 32 years (range 8-87 years), with 69 (39.4%) males and 106 (60.6%) females (P < 0.0001). Of these, 106 underwent open surgery with standard McBurney incision, nine underwent full laparotomy and 60 underwent laparoscopic surgery. Six of the laparoscopic surgeries were converted to open procedures. We recorded 159 (90.75%) classical carcinoids and 16 (9.25%) goblet cell carcinoids. Overall, 131 (75.7%) had concurrent appendicitis; classical carcinoid 72.6% versus goblet cell carcinoid 93.8%. The median size of the goblet cell carcinoids was significantly larger than classical carcinoids. Classical carcinoids were mostly distal to the base, while goblet cell carcinoids had equal distribution. It appears that the involvement of resection margins was not influenced by the surgical technique. Thirty patients required further right hemicolectomy as treatment for high-risk features; open 19 (15.9%) versus laparoscopic 11 (20.4%). CONCLUSIONS: Laparoscopic appendicectomy did not seem to adversely influence the margin clearance in appendiceal carcinoid, though we recommend that all appendicectomies should include the mesoappendix.

Henoch-Schonlein purpura in mesothelioma.

Henoch-Schonlein purpura (HSP) is primarily a childhood immunoglobulin A (IgA)-mediated illness. When adults are affected, malignancy can be associated. We present a rare case of HSP in a 75-year-old man with malignant pleural mesothelioma. He presented with episodes of dizziness and subsequently developed non-palpable purpura across his legs, arthralgia, hematuria, proteinuria, and acute renal impairment. HSP was diagnosed based on clinical and histological findings on biopsy specimens from the skin and kidney that showed a leukocytoclastic vasculitis and mesangioproliferative glomerulonephritis with IgA deposits, respectively. He was treated with high-dose oral steroids with resolution of the skin and renal manifestations of the disease. HSP is rare in adults but has been linked to cancers. This is the first report of HSP in a patient with known malignant pleural mesothelioma.

Bilateral ovarian lymphangioma (lymphangioleiomyoma).

Lymphangiomas of the ovary are rare and are usually unilateral. We present a 50-yr-old patient who presented with irregular bleeding secondary to multiple uterine leiomyomas who was found to have bilateral ovarian lymphangiomas. There was no evidence of pelvic lymphatic obstruction or of lymphadenopathy, and this appeared to exclude the possibility of acquired lymphangiectasia. The ovarian tumors were associated with a prominent smooth muscle cell component that partly surrounded many of the dilated vascular spaces to the extent that the diagnoses of lymphangioleiomyoma and lymphangioleiomyomatosis were also considered. However, there was no clinical evidence of lymphangioleiomyomatosis in other sites and the smooth muscle cells did not express melanocytic markers immunohistochemically. Lymphangioma and lymphangioleiomyoma should be considered in the differential diagnosis of bilateral, multicystic ovarian neoplasms.

IgG4-related sclerosing disease of the small bowel presenting as necrotizing mesenteric arteritis and a solitary jejunal ulcer.

Since first described in the mid 1990s, there has been burgeoning literature on IgG4-related sclerosing disease. The number of sites that may be involved is ever increasing, with the pancreas, salivary glands, and lymph nodes being the most commonly affected organs. There are no well-documented cases arising in the gastrointestinal tract. In this report, we present the first case to our knowledge of IgG4-related sclerosing disease involving the small bowel with a distinctly unusual clinicopathologic presentation. A previously well 46-year-old woman presented with a 2-year history of intermittent abdominal pain with recent worsening due to small bowel obstruction. Following imaging, which showed jejunitis with surrounding mesenteric inflammatory changes, she proceeded to a segmental small bowel resection. The resected jejunum revealed an isolated, stenosing chronic ulcer associated with a necrotizing mesenteric arteritis. A transmural inflammatory infiltrate rich in IgG4 plasma cells was seen in the wall of the bowel and mesenteric artery. Abundant IgG4 interfollicular plasma cells were also identified in a mesenteric lymph node. The serum IgG4 level was elevated at >800 mg/dL (reference range 8 to 140 mg/dL). Although phlebitis is an almost constant feature of this disease, arteritis is not described other than in the lung and aorta. In this report, we also discuss the diagnostic pitfalls and the differential diagnoses that should be considered when this condition arises in the gastrointestinal tract.