Nikhil Agrawal

Giant lymphatic cyst of omentum: a case report

BackgroundOmental cysts are rare abdominal lesions and are difficult to diagnose. Mostly they are detected incidentally during imaging studies performed for unrelated reasons.Case presentationPresentation can be both acute and chronic. Acute presentations are usually due to complication in cyst. Imaging is helpful in excluding other causes of lump abdomen.We encountered a case of giant lymphatic cyst presenting with abdominal swelling, clinically mimicking huge ovarian cyst.ConclusionThe goal of surgical therapy is complete excision of the cyst, and Omental cysts can be removed without endangering the adjacent bowel.

Activated Protein C Resistance in Deep Venous Thrombosis

Several risk factors for deep venous thrombosis (DVT) have been identified, and inherited thrombophilias constitute a significant proportion of them. The most common inherited thrombophilia is activated protein C (APC) resistance, and factor V Leiden is the most common cause of APC resistance. The high prevalence of APC resistance in Caucasians is established, and the prevalence among persons of Asian and African descent has been shown to be low in previous studies. Twenty-three patients with lower limb DVT were included in the study. Diagnosis was confirmed by duplex ultrasonography. Patients were tested for APC resistance with use of the STA Staclot APC-R system (Diagnostica Stago, Asnieres, France), as per the manufacturers guidelines. Ten patients (43.5%) tested positive for APC resistance, while 13 (56.5%) tested negative. APC resistance, although considered a rarity, has been found to have a high prevalence in patients with DVT from the northeastern region of India. APC resistance estimation should be done for all patients with DVT.

Aggressive angiomyxoma presenting with huge abdominal lump: A case report

Agressive angiomyxoma is a rare mesenchymal neoplasm. It mainly presents in females. We here present a case of angiomyxoma presenting as huge abdominal lump along with gluteal swelling. Case note is described along with brief review of literature.

Isolated splenic tuberculosis presenting with splenomegaly and pyrexia of unknown origin.

Isolated tuberculosis of spleen in young persons is an extremely rare condition. We report the rare presentation of isolated splenic tuberculosis in a patient who was young and immunocompetent, with no other organ was involved. A 15-year-old woman presented with fever of 11⁄2years. She was having pain in the abdomen off and on during last 8months. Moderate splenomegaly with fever (39.3 C) was noticed during physical examination. Ultrasound and computed tomography (CT) scan pictures were suggestive of abscesses or lymphoma. Fine-needle aspiration cytology from the splenic lesion showed Staphylococcus aureus. After 3weeks antibiotic treatment, splenectomy was carried out. Multiple small abscesses with thick, organized, purulent contents were noticed all over spleen. Gross examination of spleen showed multiple whitish nodules 1–3 cm by 1–2 cm in size, with splenic notch of 4.0 cm (Fig. 1) and histopathology confirmed tuberculosis. Splenic involvement in tuberculosis is common in miliary or disseminated tuberculosis,1 especially in AIDS patients with extrapulmonary tuberculosis.2 Pyrexia of unknown origin (PUO) is caused by tuberculosis in 5–11% of reported cases in a major series. Splenic abscess is associated with parenchymal liver disease and diabetes mellitus and affects age group >50 years.3 PUO as a result of tuberculosis is more common in patients >65 years old and those with HIV infection.4 Despite rapid advances in detection facility of tuberculosis, invasive techniques, for example, biopsy by endoscopy or operation, are needed in many cases to establish the diagnosis. Splenomegaly with PUO and investigations pointing towards abscess or lymphoma prompted us to do splenectomy, and histopathology was the final tool for diagnosing isolated tuberculosis of spleen. Diffuse hyperechogenity is shown on USG, but hypoechoic lesions are found if the lesion is necrotizing, as observed in our case. CT scan typically shows multiple rounded or ovoid lowdensity lesions 1–2 cm in diameter and without calcification. This appearance is, however, by no means specific as pyogenic splenic abscesses, lymphoma or primary or metastatic malignancies may also display similar features.5 Fine-needle aspiration under CT or ultrasound guidance is safe and often positive for acid-fast bacilli. For patients with splenomegaly and PUO, splenectomy is probably the diagnostic procedure of choice, which was carried out in our case. Our case was quite difficult to diagnose because of atypical presentations as the patient was young, immunocompetent presenting with PUO and splenomegaly without any dissemination, miliary involvement or extrasplenic foci.

Intestinal gangrene due to mesenteric vascular occlusion masquerading as strangulated inguinal hernia

Strangulated inguinal hernia may present with intestinal gangrene. However, mesenteric arterial thrombosis producing massive gangrene of the bowel as content in inguinal hernia is an entity probably not reported in the medical literature. We report a case of inguinal hernia presenting with features of strangulation, which on exploration was found to be a case of massive bowel gangrene due to superior mesenteric artery thrombosis affecting the terminal ileum, cecum, ascending colon and proximal three-fourths of the transverse colon. We think this is the first case report of superior mesenteric artery thrombosis masquerading as strangulated inguinal hernia and present it with a message that while dealing with an inguinal hernia with gangrenous bowel as the content, one should keep in mind a rare possibility of mesenteric thrombo-embolism as the cause.

Ampullary Mixed Adenoneuroendocrine Carcinoma: Surprise Histology, Familiar Management:

Introduction. Mixed adenoneuroendocrine carcinoma (MANEC) has recently been defined by the World Health Organization in 2010. These are rare tumors and MANECs of ampullary region are even rarer. Only 19 cases have been reported in literature. We present 3 cases; the largest series, second case of amphicrine tumor and first case associated with chronic pancreatitis. Methods. Retrospective review of 3 patients who were diagnosed to have ampullary MANEC. Results. All 3 patients were diagnosed preoperatively as neuroendocrine carcinoma and underwent margin negative pancreaticoduodenectomy. The histopathology revealed MANECs of small cell, mixed type in 2 patients and large cell, amphicrine type in 1 patient. The neuroendocrine component was grade 3 in all, the tumor was T3 in 2 and T2 in 1 and all had nodal metastases. Two patients received adjuvant chemotherapy and 2 of them had recurrence at 13 and 16 months. The median survival was 15 months. Conclusion. Ampullary MANECs are rare tumors. They are diagnosed on histopathologic examination of the resected specimen. Clinical presentation, management, and prognosis is similar to ampullary adenocarcinoma in literature.

Percutaneous transhepatic portal vein stenting in a patient with benign non-transplant postoperative portal vein stenosis: A case report.

Extrahepatic portal vein stenosis is caused by a variety of benign and malignant diseases and results in development of symptoms due to portal hypertension. Benign post-surgical adhesions causing portal vein stenosis in non-transplant population is an uncommon etiology of portal hypertension. Endovascular treatment of such patients with angioplasty and stenting is uncommonly reported in literature. We report a case of portal hypertension caused by benign postoperative portal vein fibrosis, successfully treated by self-expandable metallic stent.

Computed Tomography (CT) and Magnetic Resonance (MR) Findings in Xanthogranulomatous Cholecystitis: Retrospective Analysis of Pathologically Proven 30 Cases – Tertiary Care Experience

Summary Background To study CT and MR findings in xanthogranulomatous cholecystitis (XGC). Material/Methods Retrospective analysis of 30 histopathologically confirmed cases of XGC. Seventeen patients underwent CECT and 13 underwent MRI. The following features were studied – wall thickness, intramural nodules, pericholecystic stranding, wall thickness, THAD, fat in gallbladder wall, cholelithiasis, infiltration, biliary dilatation, lymph nodes, complications. Results The majority of cases (22/30) showed discontinuous mucosal lining. Discontinuous mucosal lining was seen in all cases with wall thickness >10 mm, 75% of cases with wall thickness between 3–10 mm and none in normal wall thickness (p=0.03). Diffuse wall thickening was seen in 23 cases, focal thickening in 3 and polypoidal wall thickening in 2 cases. Polypoidal thickening was seen in gallbladder carcinoma. Intramural nodules were present in 87.5% of cases with discontinuous mucosal lining. Pericholecystic stranding was seen in 19, biliary dilatation in 12, liver infiltration in 13 and fat in 7 cases. Lymphadenopathy was seen in 1 case with gallbladder carcinoma. Four cases showed a signal drop in the intramural nodules on chemical shift MRI. Conclusions Discontinuous mucosal lining is evident in xanthogranulomatous cholecystitis. Diffuse wall thickening, intramural nodules, continuous or discontinuous mucosal lining and cholelithiasis may indicate XGC rather than gallbladder carcinoma. Based on correlation with pathophysiological findings, we conclude that discontinuous mucosal lining is not an unusual finding in cases of XGC. Advances in knowledge: Being aware of the radiological findings described in this article may be helpful in making preoperative radiological diagnosis of XGC. Mucosal lining may be continuous or discontinuous in XGC.

Asymptomatic transhiatal pancreatic herniation after oesophagectomy.

Transhiatal herniation of abdominal organs after oesophageal resection and reconstruction is rare and sparsely described in the literature. The commonest organ to herniate is the colon. Pancreatic herniation has been reported twice before. We report a case of postoesophagectomy transhiatal pancreatic herniation in an asymptomatic patient.

Reno-colic arterial fistula due to penetrating abdominal trauma.

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