Rajgopal Shenoy

Jejuno-jejunal intussusception: an unusual complication of feeding jejunostomy

The jejuno-jejunal intussusception is a rare complication of jejunostomy tube placement. We are reporting a case of 33-year-old man who was suffering from absolute dysphagia due to carcinoma of cricopharynx with advanced metastatic disease, who underwent Stamms feeding jejunostomy as a part of palliative care. After 1 month he presented with colicky type of pain in the abdomen and vomiting. Sonogram of abdomen revealed a target sign and a feeding tube in a dilated jejunum. Abdominal CT proved the sonographic impression of jejuno-jejunal intussusception. He, therefore, underwent exploratory laparotomy and resection and anastomosis of the intussuscepted bowel. New feeding jejunostomy (FJ) was done distally from the anastomotic site. As per the literature this complication has been reported in Witzels jejunostomy. In our case the patient had undergone Stamms jejunostomy with placement of a Ryles tube. Intussusception should be considered if a patient comes with abdominal pain and vomiting following FJ.

Iliac crest bone graft donor site hernia: not so uncommon

A 73-year-old man, who had undergone fracture fixation of humerus with LCP plating and bone grafting, presented again with a peri-implant fracture after 1 year. A repeat surgery was contemplated and replating was performed with tricortical bone graft harvested from the iliac crest. In the postoperative period the patient developed a tender swelling at the graft site with nausea and abdominal discomfort. It was managed conservatively thinking it to be a haematoma at the graft site. In the following 2 days his symptoms worsened. A CT abdomen showed the herniation of caecum from the bone graft donor site with obstruction. The patient was taken up for emergency surgical repair, the caecum was reduced and polypropylene mesh hernioplasty was performed. The patient recovered well without recurrence in the follow-up period. Iliac crest bone graft site hernia is not so uncommon and care has to be taken while harvesting.

Endometriosis of extra-pelvic round ligament, a diagnostic dilemma for physicians

A 49-year-old multiparous woman presented with a swelling in the left groin of 6 months duration. The swelling was associated with a dull aching pain. The patient reported increase in size of the swelling during lifting of heavy weights. Menstrual history was normal and there was no increase in pain over the swelling during menstruation. She underwent a caesarean section 20 years ago and the scar had healed by primary intention. She was provisionally diagnosed to have a left-sided inguinal hernia. Ultrasonography showed a multiloculated cyst measuring 5.3×1.5×5.2 cm within the inguinal canal. The patient had excision of the cyst under spinal anaesthesia. Intraoperatively the cyst was found to arise from the left round ligament. It measured 7×6 cm extending to the left lateral vaginal wall. Histopathology revealed endometriosis of the round ligament. Her gynaecological assessment was normal and they recommended no further treatment. On follow-up the patient was asymptomatic and wound had healed well.

Aggressive fibromatosis (desmoid tumour) of the head and neck: a benign neoplasm with high recurrence

A 50-year-old man presented with a 5-month history of swelling over the right side of neck. The swelling was associated with dull aching pain radiating to the forearm without associated weakness of upper extremity or sensory loss. There was no history of trauma. On examination a fixed mass approximately 8×6 cm in size, smooth, firm in consistency, with ill-defined margins was present in the right posterior triangle. MRI scan of the neck revealed well-defined, lobulated, heterogeneously enhancing altered signal intensity mass at the root of neck. Debulking of the tumour was performed in view of its close proximity to the brachial plexus. Histopathology revealed aggressive fibromatosis (AF). AF is a benign fibrous neoplasm arising from fascia, periosteum and musculoaponeurotic structures of the body. AF in the head and neck region tends to be locally aggressive with a nature to invade bone and soft tissue structures.

Pancreatic cancer presenting as a Sister Mary Joseph's nodule

A 69-year-old man presented with a painful umbilical nodule of 1 month duration. On examination the nodule was blackish in colour with a serous discharging fluid and was 2×2 cm in size, tender and fixed to the skin. There were no scars or sinuses at the umbilicus and no palpable mass or organomegaly on systemic examination. The patient underwent wide local excision of the skin nodule and on histopathology was reported as metastatic adenocarcinoma of the skin. A CT of the abdomen was performed to look for the primary site, which showed a 5×4 cm lesion in the tail of the pancreas. A biopsy from the pancreatic lesion was taken which was reported as an adenocarcinoma. CA19–9 was more than 1000 U/mL. The patient was advised palliative chemotherapy with gemcitabine. He was unwilling to take any further treatment in view of the advanced nature of the disease.

Be Careful with an IV Line.

Obtaining an intravenous (IV) access is a simple procedure which can be done in almost any hospital setting. One of the most dreaded complications of this procedure is an inadvertent intra-arterial cannulation. This can result in an accidental injection of medications intra-arterially, which can potentially lead to life altering consequences. In the hope that these types of events can be prevented, we are presenting a case of a 57-year-old male who underwent bougie dilatation for an oesophageal stricture and was accidentally given medication for pain management intra-arterially through an improperly placed IV line, which resulted in ischaemia, gangrene and subsequent loss of the hand. Those who try to obtain an IV access should always be on the lookout for possible clues that can prevent an inadvertent IA injection, especially if cannulation is in an area where an artery is in close proximity to a vein; these clues include but are not limited to the following: a bright-red flash of blood in the cannula, pulsatile movement of blood in the IV line, and intense pain or burning at the site of injection. These signs, as well as educating the patient on early symptoms of ischaemia, may allow early action to be taken, to prevent irreparable damage. We always have to be careful when we insert an I.V line.

Primary colonic signet ring cell carcinoma in a young patient

A 28-year-old woman presented with colicky abdominal pain for 3 months. Pain was associated with episodes of vomiting, abdominal distension and constipation. She also had loss of weight for this duration. General physical examination was unremarkable and the abdomen was soft, with no palpable organomegaly. A CT of the abdomen showed small bowel and ascending colon dilation with multiple air fluid levels. There was also a short segment of circumferential bowel wall thickening and luminal narrowing in the hepatic flexure with sudden transition of bowel diameter. She underwent a right hemicolectomy after necessary preoperative investigations. Histopathology revealed signet ring cell carcinoma (SRCC). This case highlights the importance of detecting such a lesion in a young, otherwise fit woman. The challenge lies in early diagnosis and awareness of general practitioners about this aggressive form of colonic tumours.

Extragenital aggressive angiomyxoma of the axilla and the chest wall.

Aggressive angiomyxomas are uncommon mesenchymal tumours which most often arise in the perineal and the pelvic regions in women. Extragenital aggressive angiomyxonas are extremely rare. We are reporting a young male with an aggressive angiomyxoma which involved the axillary region and extended into the anterior chest wall, which demonstrated its characteristic histomorphological features. The diagnosis was confirmed by immunohistochemistry. A careful histological examination, along with immunohistochemistry, aids in diagnosing this lesion and differentiating it from tumours which have similar histologies.

Intestinal Ganglioneuromatosis with Peri-intestinal Neurofibroma Limited to the Gastrointestinal Tract Clinically and Morphologically Mimicking Crohns Disease

Ganglioneuroma is a benign neurogenic tumor composed of ganglion cells, nerve fibers, and supporting cells. Intestinal ganglioneuromas are rare tumors more often identified in the adults as solitary polypoid ganglioneuromas, ganglioneuromatous polyposis and diffuse ganglioneuromatosis, presenting with abdominal pain, diarrhea, thickening of the bowel wall, and stricture formation. Diffuse ganglioneuromatosis is typically associated with multiple endocrine neoplasia, neurofibromatosis Type 1 and Cowden syndrome. In this case report, we describe a case of diffuse and polypoid ganglioneuromatosis along with peri-intestinal neurofibroma in a 30-year-old female with no syndromic afflictions. A 30-year-old female was investigated for recurrent alternating episodes of constipation and diarrhea since 15 days, associated with abdominal distension and palpable mass per abdomen. On contrast enhanced computed tomography abdomen and pelvis, multifocal strictures with subacute intestinal obstruction was noted with possibilities of Crohn’s disease or tuberculosis. Surgically resected terminal ileum and ascending colon had multiple linear ulcers, pseudopolyps, and cobblestone appearance. On histopathological examination of the resected specimen, diagnosis of intestinal ganglioneuromatosis (polypoid and diffuse) with suture granuloma and peri-intestinal neurofibroma was given. History elicited for similar prior complaints showed nonspecific ileocolitis on biopsy 2 years earlier. She also gave history of surgery for resection and anastomosis 6 years back. We report a patient with intestinal ganglioneuromatosis in whom clinical and radiological findings mimicked those of Crohn’s disease/tuberculosis. Despite its rarity, intestinal ganglioneuromatosis should be considered in patients with features suggestive of Crohn’s disease/tuberculosis on radiological investigations who have nonspecific mucosal biopsy findings and intractable symptoms despite medical treatment. Ganglioneuroma is a benign neurogenic tumor composed of ganglion cells, nerve fibers and supporting cells. In this case report, we describe a case of 30-year-old female with diffuse and polypoid ganglioneuromatosis along with peri-intestinal neurofibroma with no syndromic afflictions in whom clinical and radiological findings mimicked those of Crohn’s disease/tuberculosis. Despite its rarity, intestinal ganglioneuromatosis should be considered in patients with features suggestive of Crohn’s disease/tuberculosis.

Intestinal ganglioneuromatosis with peri-intestinal neurofibroma limited to the gastrointestinal tract mimicking Crohn’s disease

S S141 characteristic. As patients with TDT-negative T-ALL/LBL tend to show worse outcome, it is important to remember that lack of TDT expression is expected in subsets of T-ALL/LBL. This pitfall should not preclude a correct diagnosis. 71. INTESTINAL GANGLIONEUROMATOSIS WITH PERI-INTESTINAL NEUROFIBROMA LIMITED TO THE GASTROINTESTINAL TRACT MIMICKING CROHN’S DISEASE Sushmitha Malpe Gopal, Anuradha C.K. Rao, Ranjini Kudva, Rajgopal Shenoy 1Department of Pathology, Melaka Manipal Medical College, and 2Department of Pathology and Surgery, Kasturba Medical College, Manipal, Manipal University, Karnataka, India Introduction: Ganglioneuroma is a benign neurogenic tumor composed of ganglion cells, nerve fibers and Schwann cells. Intestinal ganglioneuromas are rare tumors more often identified in the adults as solitary polypoidganglioneuromas, ganglioneuromatous polyposis and diffuse ganglioneuromatosis, presenting with abdominal pain, diarrhoea, thickening of the bowel wall and stricture formation. Diffuse ganglioneuromatosis is typically associated with multiple endocrine neoplasia, neurofibromatosis type 1 and Cowden syndrome. In this case report, we describe a case of diffuse and poylpoidganglioneuromatosis along with peri-intestinal neurofibroma in a 30 year old female with no syndromic afflictions. Case report: 30 year old female was investigated for recurrent alternating episodes of constipation and diarrhoea since 15 days associated with abdominal distension and palpable mass per abdomen. On CECT abdomen and pelvis, multifocal strictures with subacute intestinal obstruction was noted with possibilities of Crohns disease or tuberculosis. Surgically resected terminal ileum and ascending colon showed multiple linear ulcers, pseudopolyps and cobblestone appearance. On histopathological examination of the resected specimen, diagnosis of intestinal ganglioneuromatosis (polypoid and diffuse) with suture granuloma and peri-intestinal neurofibroma was given. History elicited for similar prior complaints showed nonspecific ileocolitis on biopsy 2 years earlier. She also gave history of surgery for resection and anastomosis 6 years back. Conclusion: We report a patient with intestinal ganglioneuromatosis in whom clinical and radiological findings mimicked those of Crohn’s disease/tuberculosis. Despite its rarity, intestinal ganglioneuromatosis should be considered in patients with findings of Crohn’s disease/tuberculosis on radiological investigations who have intractable symptoms despite medical treatment. 72. HISTOPATHOLOGICAL STUDY OF UPPER GASTROINTESTINAL ENDOSCOPIC BIOPSY IN PATIENTS WITH DYSPHAGIA AND DYSPEPSIA IN SOUTH WESTERN COAST OF INDIA Sushmitha Malpe Gopal, G.N. Srinivas, Rashmi Vaidya 1Melaka Manipal Medical College, Manipal University, Manipal, 2SRL Diagnostics, Mysore, and 3AJ Institute of Medical Sciences, Mangalore, India Background: Patients with non-neoplastic and neoplastic lesions of upper gastrointestinal tract (GIT) exhibit important alarming symptoms like dysphagia and dyspepsia. Upper gastrointestinal endoscopic biopsy is an effective and appropriate investigation to assess these patients. Aims: The aim of this study is to identify various lesions of the upper GIT in patients presenting with dysphagia and dyspepsia along with endoscopic and clinical correlation. For early identification of malignant lesions, screening of premalignant lesions and to differentiate non neoplastic lesions from neoplastic lesions and thus help in its appropriate management. Method: 200 consecutive endoscopic biopsy samples received in histopathology laboratory in and around Mangalore, India for a period of two years was subjected for histopathological examination. All the samples received in the histopathology laboratory sent in 10% formalin was processed, haematoxylin and eosin staining was done. Special stains were done wherever necessary. Results: 80% of the patients presented with dyspepsia. The most common lesion encountered in the oesophagus was malignant lesions followed by premalignant lesions, benign neoplasms and non-neoplastic lesions. The most commonly encountered gastric lesion were non neoplastic lesions followed by malignancy, premalignant lesions and benign neoplasm. Among the duodenal biopsies, non-neoplastic lesions were most common followed by malignancy. Conclusion: The fibreoptic diagnostic upper GI endoscopic biopsy is relatively less invasive, simple, safe, well tolerated procedure, cost effective and provides good diagnostic yield in confirming various upper GIT lesions. There is concordance of endoscopic biopsy findings with post biopsy resected specimens. In routine clinical practice, histopathology is the ‘gold standard’ for the definitive diagnosis of various lesions. 73. INTRAVASCULAR HISTIOCYTOSIS (IVH): A CASE REPORT K. Manoharan, B. Dutta Department of Anatomical Pathology, Laverty Pathology, NSW,