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The most common causes of small bowel obstruction (SBO) are adhesions, Crohn's disease, neoplasms, and hernias. Internal hernias are rare, and they occur when the small bowel herniates through a defect in the abdominal cavity. The occurrence of internal hernias due to a broad ligament defect is very rare and accounts for 4%-7% of cases of internal hernia. We present a case of a 71-year-old female who was previously healthy with no significant past medical or surgical history and who presented with symptoms of small bowel obstruction. Imaging with X-ray and computed tomography (CT) confirmed the diagnosis, but not the etiology. A decision was made to perform a laparoscopy to manage the obstruction, which revealed a healthy small bowel loop that herniated through a defect in the right broad ligament. Acute abdominal pain due to intestinal obstruction is a relatively common surgical emergency. Internal hernias are the consequence of the herniation of a bowel loop, most commonly the small bowel, through a peritoneal or mesenteric defect into a compartment in the abdominal and pelvic cavity, and they have a high mortality rate than can be higher than 50%. CT imaging is very useful in the diagnosis of internal hernias, although it may not always reveal the etiology. To facilitate wider recognition, broad ligament hernia should be in the differential diagnosis of internal hernias evident in the pelvis on CT imaging. Early recognition of small bowel obstruction caused by broad ligament internal hernia allows for prompt surgical management and vastly facilitates postoperative recovery. Although most surgeons opt for a laparotomy approach to manage such cases, a laparoscopic approach is feasible.
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INTRODUCTION: Langerhans' Cell Histiocytosis is a rare disease of unknown etiology, the pathogenesis of which involves both reactive and neoplastic processes. Despite potential resolution with conservative management, a rare recurrence in a distant site after 3 years from presentation in this case highlights the variability in the course of the disease and the need for larger studies to enable recognition and evidence-based management. CASE PRESENTATION: We present an unusual case below of a 25-year-old gentleman who presented with sternal pain and tenderness. Imaging showed a lytic lesion in the sternum which resolved spontaneously with oral analgesia. He presented 3 years later with back pain and a similar lytic lesion in the iliac bone was found and diagnosed as recurrent Langerhans Cell Histiocytosis with a biopsy. CLINICAL DISCUSSION: There is a diverse array of documented presentations of Langerhans Cell Histiocytosis involving single or multiple systems, while its progression and outcomes are equally unpredictable from the current literature. In order to facilitate wider recognition, Langerhans Cell Histiocytosis should be considered in the differential diagnosis of recurrent lytic bone lesions. CONCLUSION: Although this is a rare disease, there is currently an unmet need for understanding the determinants of recurrence and response to treatment.
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INTRODUCTION AND CLINICAL IMPORTANCE: Intramuscular myxoma (IM) is a rare benign soft tissue tumor that involves the musculoskeletal system with a reported incidence of 0.1-0.13 per 100,000. The mean age of diagnosis is 40-70 years of age, with female predilection. The most common site of involvement is the thigh, however, it may present in other areas such as the upper arm, calf, and buttock. CASE PRESENTATION: A case of a 45-year-old female without a significant past medical or surgical history who presented with 3-year history of a slow-growing, painless mass in her left upper thigh. MRI scan was performed which showed intramuscular soft tissue mass lesion 9 × 6 × 4.5 cm implicating the left distal vastus medialis muscle. A fine needle aspiration was inconclusive so a core needle biopsy was performed which was suggestive of intramuscular myxoma. A complete surgical excision of the mass was done and the postoperative period was uneventful and patient was discharged home. The final histopathological examination confirmed the diagnosis of intramuscular myxoma. DISCUSSION: Intramuscular myxoma is a rare benign soft tissue neoplasm. 50 % of cases commonly occur in the thigh. IM has an unknown etiology, however, the literature has showed common gene mutations such as the GNAS gene mutations (Guanine nucleotide binding protein, alpha stimulating). Imaging modalities such as ultrasound, computed tomography (CT) and magnetic resonance imaging (MRI) are useful in diagnosis of soft tissue mass but not specific to intramuscular myxoma. Histopathological examination is the gold standard for diagnosis. The treatment of choice is surgical excision with clear margins to prevent recurrence, which is extremely rare. CONCLUSION: Intramuscular myxomas, although benign and rare, should be in the differential diagnosis of soft tissue lesions due to the similarity they share with malignant tumors such as sarcomas. Histopathological examination is the gold standard for diagnosing a soft tissue lesion and surgical excision is the treatment of choice.
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BACKGROUND: COVID-19 vaccinations have been shown to be effective in reducing risk of severe infection, hospitalization, and death. They have also been shown to be safe and effective in patients with inflammatory bowel disease (IBD) who are receiving biologic therapies. In this study, we aimed to evaluate the prevalence of vaccination among patients receiving biologic therapies for IBD. METHODS: A single-center prospective cross-sectional study conducted at a tertiary care inflammatory bowel disease center in Kuwait. Data from patients with inflammatory bowel disease (IBD) who attended the gastroenterology infusion clinic from 1 June 2021 until 31 October 2021 were retrieved. Patients who received infliximab or vedolizumab at least six weeks before recruitment were included. The primary outcome was prevalence of COVID-19 vaccination. The secondary outcome was to assess whether prevalence of COVID-19 vaccination differed based on sex, age, type of biologic therapy and nationality. RESULTS: The total number of inflammatory bowel disease (IBD) patients enrolled in the study was 280 (56.0% male and 44.0% female). Of the total, 112 (40.0%) patients were diagnosed with ulcerative colitis and 168 (60.0%) with Crohn's disease. The number of ulcerative colitis patients who were vaccinated was 49 (43.8%) and the number of Crohn's disease patients who were vaccinated was 68 (40.5%). The median age was 33.2 years and BMI was 24.8 kg/m2. With respect to the total number of patients, 117 (41.8%) were vaccinated with either BNT162b2 or ChAdOx1 nCoV-19 and 163 (58.2%) were not vaccinated. Female patients were more likely to receive the vaccine compared to male patients (83.0% vs. 63.8%, p < 0.001). In addition, patients above the age 50 were more likely to receive the vaccine than patients below the age of 50 (95.6% vs. 31.2% p < 0.001). Expatriates were more likely to receive the vaccine than citizens (84.8% vs. 25.0%, p < 0.001). There was no statistical difference between patients on infliximab and vedolizumab with regard to prevalence of vaccination (40.0% vs 48.0%, p = 0.34). CONCLUSION: The overall prevalence of COVID-19 vaccination among patients with inflammatory bowel disease (IBD) on biologic therapies was lower than that of the general population and world health organization (WHO) recom-mendation. Female patients, patients above the age of 50, and expatriates were more likely to receive the vaccine. Physicians should reinforce the safety and efficacy of COVID-19 vaccines among patients, especially IBD patients on biologic therapies, who express hesitancy towards them.