Double cecal appendix is a rare anatomical variation. Approximately 100 cases have been reported worldwide. It is usually diagnosed incidentally during emergency appendectomies due to inflammatory processes in the cecal appendix. Case presentation: male, white, 36 years old, obese, presenting with pain in the lower abdomen for 24 h followed by nausea, vomiting and mild fever. He was subjected to additional tests, with the leukogram showing leukocytosis and abdominal ultrasonography depicting cecal appendix with thickened wall, locally associated with small quantities of liquid and intestinal loop obstruction. He underwent laparotomy, revealing acute appendicitis. Another intestinal loop obstruction was identified next to the ileum, leading to recognizing another cecal appendix after local dissection. Double appendectomy and segmental iliectomy were performed although not needed. Results of the anatomopathological examination of the surgical samples showed acute inflammation in the two cecal appendices. So, performing a routine retroperitoneal release and a complete cecum evaluation during such surgical procedures is recommended and suggested due to the possibility of not identifying a second cecal appendix.
Appendix; Anatomic variation; Appendicitis; Appendectomy; General surgery
Duodenal duplication cysts are benign rare congenital anomalies reported mainly in the pediatric population, but seldom in adults. Symptoms depend on the type and location and can present as abdominal pain, distension, dysphagia or dyspepsia. They have been reported to be responsible for duodenal obstruction, pancreatitis and, in rare cases, gastrointestinal bleeding. We present a case of a duodenal duplication cyst in a 43-year-old man presenting as melena. Initial gastroduodenoscopy and colonoscopy did not reveal any bleeding focus. However, the patient began passing melena after 3 d, with an acute decrease in hemoglobin levels. Subsequent studies revealed a duplication cyst in the second portion of the duodenum which was surgically resected. Histology revealed a duodenal duplication cyst consisting of intestinal mucosa. There was no further bleeding and the patient recovered completely. In rare cases, duodenal duplication cysts might cause gastrointestinal bleeding and should be included in the differential diagnosis.
Gastrointestinal hemorrhage; Duodenum; Duplication
Spontaneous non-occlusive ischemic colitis involving the cecum alone (isolated cecal necrosis) is a rare condition that is generally due to a low-flow state: shock. It presents with right lower quadrant abdominal pain and may resemble acute appendicitis. Little is known about postoperative ischemic necrosis of the remaining colon after surgical treatment of isolated cecal necrosis. We report four cases of isolated cecal necrosis mimicking acute appendicitis seen at our institution within a 4-year period.
The patients were two men and two women with a mean age at diagnosis of 59 years (range 46-68). The patients were of Turkish ethnic origin. All patients presented to the emergency room with acute abdominal pain and had symptoms of nausea and vomiting. The medical histories for three of the patients revealed end-stage renal failure requiring hemodialysis. The other patient had chronic obstructive pulmonary disease. Right hemicolectomy with anastomosis was performed in three patients and cecal resection with ileocolostomy was performed in the remaining one patient. All of the patients healed without complications. Median follow-up of patients was 24.5 (range: 17-37) months. There was no recurrence of ischemia in the remaining colon during the follow-up period of the patients.
Isolated cecal infarction should be included in the differential diagnosis of acute pain in the right lower quadrant of the abdomen, especially in those patients on chronic hemodialysis. While diffuse ischemic disease of the intestine has high morbidity, mortality and recurrence rates, patients with isolated cecal necrosis have a good prognosis with early diagnosis and surgical treatment compared to those with diffuse ischemic disease.
Duplications of the alimentary tract are very rare. A one-month-old female presented with symptoms of anorexia, vomiting and continuous watery diarrhea. The plain abdominal radiograph showed thickened intestinal wall and signs of small bowel obstruction. The fevers, vomiting, and continuous wartery diarrhea persisted despite antibiotics, and worsened. The patient failed to respond to medical managements, 27 hours after admission, the patient died due to multiple organ failures. The autopsy was performed, small bowel obstruction due to an ileocecal duplication cyst (3 × 3 cm) was recognized. The ileocecal duplication cyst was attached to the ileum which was changed edematous and necrotic. This potential diagnosis should be borne in mind for a patient who complains of abdominal symptoms with an unknown cause, and duplication cyst should be recognized as a fatal cause in infant.
sudden unexpected death; small bowel obstruction; ileocecal duplication cyst
In a 20-year period at the Los Angeles Children's Hospital, 46 infants and children have had operation for cysts within the abdomen. The age range of patients was from newborn to 13 years. Most of them were under four years old. There were four general groups of these cysts. (1) About one-half were cysts of the ovary, some of them serous and some dermoid. These cysts are attached by a stalk that often twists, causing gangrene or rupture with acute symptoms simulating appendicitis. (2) Next in frequency were cysts arising in the mesentery of the intestine. They usually caused little trouble until by their size (up to a 2-quart capacity) they created pressure and obstruction in the intestine. (3) Enteric cysts were found in four patients. (4) Cysts of the pancreas were present in three of the children.
X-ray examination was helpful in diagnosis. Usually the type of cyst was not determined until operation was done. Transection of the intestinal tract sometimes was necessary for removal of the cyst. Surgical correction was satisfactory in 44 of the 46 cases.
A twisted loop of the bowel and its mesentery on a fixed point is known as volvulus and it may arise more frequently in the sigmoid colon and cecum. Cecal volvulus as an uncommon cause of acute intestinal obstruction is axial twist of the cecum, ascending colon and terminal ileum around their mesenteric pedicles. Although there are many different etiologic and predisposing factors for cecal volvulus, exact etiology is most likely multifactorial in presence of mobile cecum. Its clinical presentation is highly variable, ranging from intermittent episodes of abdominal pain to abdominal catastrophe depending on pattern, severity and duration of cecal volvulus causing intestinal obstruction. Due to its rarity and nonspecific presentation, preoperative diagnosis is rarely achieved in most cases. Abdominal radiographs as an initial diagnostic test are usually abnormal and can detect cecal volvulus in half of cases. Nowadays, computerized tomography is used for more accurate diagnosis and differentiation from other acute emergent conditions. Resection with right hemicolectomy and primary ileocolic anastomosis has been recommended for surgical treatment of cecal volvulus.
Intestinal obstruction; Intestinal volvulus; Cecum; Diagnosis; Surgery
This is an analysis of 6 patients with enteric duplications seen over an 8 year period at the Department of Pediatric Surgery, Dongsan Medical Center. They were all males but one. All duplications were cystic, and single except one. Locations of duplications were in the duodenum in one patient, in the jejunum in one, and in the terminal ileum in four. Five of the 6 patients were seen within 1 year of life. Three were newborn infants who had symptoms of intestinal obstruction with palpable mass since birth. Duplication cyst acted as a leading point of intussusception in 4 month and 8 month old infants respectively. One jejunal duplication was found in an 11-year-old boy who had malrotation of the midgut with Ladd's bands. Clinical presentation, embryogenesis of duplication, and management are discussed.
A 70-year-old male presenting with abdominal pain was clinically diagnosed to have chronic intestinal obstruction due to lesion in ileo-cecal junction based on barium meal follow through. He underwent right hemicolectomy and the lesion was ascertained to be an intraluminal hydatid cyst in the caecum. Intraluminal cecal hydatid cysts can mimic malignancy on radiological investigations. It should be considered as a differential diagnosis in patients presenting with intestinal obstruction in endemic regions for hydatid disease.
Chronic intestinal obstruction; hydatid cyst; intraluminal caecal hydatid cyst
To investigate whether neonatal dacryocystoceles and dacryocystitis are associated with nasolacrimal duct cysts, and to report the outcomes of treatment of these disorders.
This was a retrospective medical record review of two groups of infants with nasolacrimal duct (NLD) obstruction. The first group had dacryocystoceles with or without dacryocystitis. The second group had NLD obstruction with symptoms severe enough to require early NLD probing. All of the patients underwent NLD probing and nasal endoscopy. When present, NLD cysts were removed.
In the first group, 33 infants had dacryocystoceles. Acute dacryocystitis was present in 16 patients, 12 had noninfected dacryocystoceles that did not resolve, and 5 had dacryocystoceles that resolved but severe symptoms persisted. All of the patients had NLD cysts that were surgically removed. The symptoms resolved after surgery in 31 patients (94%). In the second group, 27 infants less than 6 months old without dacryocystoceles underwent early NLD probing and endoscopy due to severity of symptoms. Twelve (44%) of these patients had NLD cysts. The symptoms resolved in 11 (92%) of 12 patients following NLD probing and cyst removal.
Neonatal dacryocystoceles are almost always associated with NLD cysts. The success rate of NLD probing and endoscopic cyst removal in these patients is excellent. Nasolacrimal duct cysts also are present in many young infants with severe symptoms of NLD obstruction. Nasal endoscopy is an important adjunct to the management of these infants.
•Although, MD is the most common congenital condition of the GI tract, the clinical diagnosis of MD is difficult to make.•Most cases of MD are found incidentally during a surgical procedure for another reason.•The mainstay treatment would be resection of the diverticulum or the segment of the bowel affected by the pathology.
Meckel's diverticulum is the most common congenital anomaly of the small intestine. Common complications related to Meckel's diverticulum include hemorrhage, intestinal obstruction and inflammation. Acute large bowel obstruction is a rare complication of Meckel's diverticulum and in the presented case it is caused by volvulus.
PRESENTATION OF CASE
We report a 39 year old female who presented with the diagnosis of a large bowel obstruction occurring as a result of cecal volvulus caused by adhesions of a perforated diverticulum.
The reported case presents one of the rare complications of MD, which is volvulus. The case described above presented with signs and symptoms suggestive of acute intestinal obstruction and radiological findings suggestive of cecal volvulus. The patient was taken to the operation room for exploration and we discovered the presence of a perforated MD. The main treatment of such case is to perform diverticulectomy in all symptomatic patients.
MD is mostly identified intraoperatively. Knowledge of the pathophysiologies by which MD can cause complications such as volvulus is important in order to plan management.
Meckel's diverticulum; Cecal volvulus; Volvulus
Previously, it had been shown that an avirulent strain of Salmonella typhimurium, SL5316, with wild-type lipopolysaccharide (LPS) was a far better colonizer of the streptomycin-treated CD-1 mouse large intestine, was far more motile, did not bind to mouse intestinal mucus nearly as well as, but penetrated through a layer of intestinal mucus in vitro far better than an almost isogenic LPS-deficient transductant, SL5325. In the present investigation, a nonflagellated transductant, SL5681, and a nonchemotactic transductant, SL5784, were isolated from SL5316 and tested for relative colonizing ability versus SL5316 (smooth) and SL5325 (rough) in streptomycin-treated mice. In addition, the Salmonella strains were tested for their ability to grow together in cecal intestinal mucus and in cecal luminal contents, for their tumbling and swimming activities after growth in cecal mucus, and for their ability to adhere to and travel through cecal mucus in vitro. The data show that the nonflagellated and nonchemotactic derivatives colonized large intestine nearly as well as their parent and were far better colonizers than the LPS-deficient mutant, that all the strains grew equally well in cecal mucus but did not grow in cecal luminal contents, and that cecal mucus-grown strains lost tumbling and swimming activities. Furthermore, the LPS-deficient strain adhered to cecal mucus far better but penetrated mucus far worse than did the nonflagellated transductant, the nonchemotactic transductant, and the parent. Thus, motility and chemotaxis do not appear to play a major role in the ability of the avirulent S. typhimurium strains to colonize the mouse large intestine, colonization may require growth in cecal mucus but does not depend on growth in cecal luminal contents, growth in cecal mucus inhibits S. typhimurium motility, and increased adhesion of the LPS-deficient mutant to cecal mucus and its poor ability to penetrate cecal mucus may play a role in its poor intestine-colonizing ability.
Lipoma within jejunal duplication presenting as abdominal bloating and partial intestinal obstruction is an exceptional clinical entity. We report a case of 68-year-old man complaining of abdominal bloating for 10 d due to multiple lipomas arising from jejunal duplication cysts. Only a few cases of a single lipoma within a Meckel’s diverticulum giving rise to this clinical scenario have been reported in the English language literature. However, no case of multiple lipomas within jejunal duplication cysts has been reported. We present a case in which double-balloon endoscopy revealed a small intestinal structure changed into Meckel’s diverticulum-like cavities containing several lipomas. This case highlights intestinal lipoma as an uncommon cause of adult intussusceptions, which should be included in the differential diagnosis of small intestinal obstruction and appropriate examinations should be chosen.
Duplication cyst; Lipoma; Double-balloon endoscopy; Jejunum; Intestinal obstruction
Midgut malrotation is a congenital anomaly presenting mainly in the childhood. Its presentation as an acute intestinal obstruction is extremely rare in adults usually recognized intra-operatively, therefore a high index of suspicion is always required when dealing with any case of acute intestinal obstruction.
PRESENTATION OF CASE
We report two cases of young adults who presented with symptoms of acute intestinal obstruction and were diagnosed intra-operatively as cecal volvulus and paraduodenal hernia, respectively, caused by midgut malrotation. Post-operative CT scan confirmed these findings.
Malrotation of the intestinal tract is a product of an aberrant embryology. The presentation of intestinal malrotation in adults is rare (0.2–0.5%). Contrast enhanced CT can show the abnormal anatomic location of a right sided small bowel, a left-sided colon and an abnormal relationship of the superior mesenteric vein (SMV) situated to the left of the superior mesenteric artery (SMA) instead of to the right.
Anomalies like midgut malrotation can present as an operative surprise and awareness regarding these anomalies can help surgeons deal with these conditions.
Midgut malrotation; Acute intestinal obstruction; Cecal volvulus; Paraduodenal hernia
Duodenal duplication cyst is a rare anomaly, totaling only 4% to 12% of gastrointestinal duplications, and is usually encountered during infancy or in early childhood. Most are commonly located posterior to the first or second portion of the duodenum. Presenting signs and symptoms include vomiting, decreased oral intake, periumbilical tenderness, abdominal distention, obstructive jaundice, acute pancreatitis, and gastrointestinal bleeding. The traditional treatment of a duodenal duplication cyst has been complete surgical resection, but very few cases of endoscopic treatment have been reported in the literature. Here, we report a case of duodenal duplication cyst that was manifested by a duodenal polyp.
Duodenum; Duplication cyst; Endoscopic resection
Mesenteric cysts are rare intra-abdominal tumors. Mesenteric cysts are usually asymptomatic and are incidentally detected during physical or radiological examination. Although uncommon, complications such as infection, bleeding, torsion, rupture and intestinal obstruction cause an acute abdomen. Spontaneous infection is a very rare complication. We present a case of infected mesenteric cysts in the ascending colon, which caused an acute abdomen. A 26-year-old woman was admitted to our hospital with acute abdominal pain. She had a painful mass in the right abdomen on physical examination. Abdominal computed tomography showed a hypodense cystic mass with septation at the mesenteric region of the ascending colon. A laparotomy revealed two cystic tumors at the mesenteric region of the ascending colon. She underwent a right hemicolectomy. The two cysts were filled with a yellowish turbid fluid. The walls of both two cysts were lined with a thin fibrotic membrane without any epithelial cell. They were diagnosed as psuedocysts with E. coli infection. Mesenferic cysts may cause life-threatening complications. Mesenteric cyst, even if it is asymptomatic and was diagnosed incidentally, should be removed completely.
Mesenteric cyst; Infection; Abdomen, acute
Gastrointestinal duplications are an uncommon congenital abnormality that manifest before the age of two in 80% of cases. Ileal duplication is the most common while colonic duplication, either cystic or tubular, occurs in 10%-15% of cases and remains asymptomatic and undiagnosed in most cases. Mostly occurring in pediatric patients, colonic duplication is encountered in adults in only a few cases. The most common clinical manifestations are abdominal pain and intestinal obstruction. Rarely, duplications present with signs of acute abdomen or acute bleeding. This study reports a case of colonic duplication in an adult who presented with chronic constipation. Complete diagnostic workup was made on several occasions during the previous eight year period, but no pathology was found and chronic constipation was attributed to hypothyroidism caused by long standing Hashimoto thyroiditis. Multislice CT, performed because of abdominal distension, defined colonic pathology but the definite diagnosis of duplication of the transversal colon was made at operation. The cystic duplication and the adjacent part of the ascending and transversal colon were excised en-block. This study implies that colonic duplication, though uncommon, should be included in the differential diagnosis of chronic constipation even when precipitating factors for constipation, such as hypothyroidism are present.
Colonic duplication; Constipation; Abdominal distension; Hypothyroidism
Chylolymphatic mesenteric cysts are rare entities with variable presentations and this has surgical implications in the pediatric age group.
We carried out a retrospective analysis of the clinical and histopathological records of pediatric patients diagnosed and treated for chylolymphatic mesenteric cysts at our institute from 1998 to 2008. Eight patients met the histopathological criteria of chylolymphatic mesenteric cyst. These patients were in the age range 18 months to 10 years with a mean age of 4.5 years. Of these eight patients, four presented with an abdominal lump, and two each with abdominal pain and acute intestinal obstruction. On clinical examination, five out of the eight patients had a palpable abdominal mass. Laparotomy and complete excision of the cyst along with the involved gut was performed in all patients. There were no postoperative complications or any recurrence during the follow-up period which ranged from 4 months to 8 years.
Although very rare, chylolymphatic mesenteric cyst should be kept in mind as one of the differential diagnoses of cystic masses of the abdomen including cystic lymphangioma. Ultrasonography and computed tomography suggest the diagnosis but histopathological examination is required for confirmation. Complete excision of the cyst yields excellent results.
Intestinal duplications are rare developmental anomalies that can occur anywhere along the gastrointestinal tract. Rectal duplication cysts account for approximately 4% of all duplication cysts. They usually present in childhood with symptoms of mass effect, local infection or more rarely with rectal bleeding from ectopic gastric mucosa.
PRESENTATION OF CASE
A 26 year old male presented with a history of bright red blood per rectum. On examination a mucosal defect with an associated cavity adjacent to the rectum was identified. This was confirmed with rigid proctoscopy and CT scan imaging. A complete transanal excision was performed.
Rectal duplication cysts are more common in pediatric patients. They more frequently present with symptoms of mass effect or local infection than with rectal bleeding. In adult patients they are a rare cause of rectal bleeding. Definitive treatment is with surgical excision. A transanal, transcoccygeal, posterior sagittal or a combined abdominoperineal approach may be used depending on anatomic characteristics of the duplication cyst.
We present a rare case of a rectal duplication cyst presenting in adulthood with rectal bleeding, managed with transanal excision.
Rectal duplication cyst; Adult; Rectal bleeding
The sympathetic neurotransmitter norepinephrine has been found to increase mucosal adherence of enterohemorrhagic Escherichia coli O157:H7 in explants of murine cecum and porcine distal colon. In the present study, we tested the hypothesis that norepinephrine augments the initial, loose adherence of this important pathogen to the intestinal mucosa. In mucosal sheets of porcine cecum or proximal, spiral and distal colon mounted in Ussing chambers, norepinephrine (10 µM, contraluminal addition) increased mucosal adherence of wild-type E. coli O157:H7 strain 85–170; in the cecal mucosa, this effect occurred within 15 – 90 min after bacterial inoculation. In addition, norepinephrine transiently increased short-circuit current in cecal and colonic mucosal sheets, a measure of active anion transport. Norepinephrine was effective in promoting cecal adherence of a non-O157 E. coli strain as well as E. coli O157:H7 eae or espA mutant strains that are incapable of intimate mucosal attachment. Nerve fibers immunoreactive for the norepinephrine synthetic enzyme dopamine β-hydroxylase appeared in close proximity to the cecal epithelium, and the norepinephrine reuptake blocker cocaine, like norepinephrine and the selective α2-adrenoceptor agonist UK-14,304, increased E. coli O157:H7 adherence. These results suggest that norepinephrine, acting upon the large bowel mucosa, modulates early, non-intimate adherence of E. coli O157:H7 and probably other mucosa-associated bacteria. Sympathetic nerves innervating the cecocolonic mucosa may link acute stress exposure or psychostimulant abuse with an increased microbial colonization of the intestinal surface. This in turn may alter host susceptibility to enteric infections.
Intimin; Type III secretion system; Mucosa-adherent bacteria; Norepinephrine; Cocaine; Enteric nervous system
Adult intussusception is a rare entity accounting for only 5% of all intussusceptions and causes approximately 1% of all adult intestinal obstructions. Unlike paediatric intussusceptions which are usually idiopathic, there is usually a lead point pathology which might be malignant in up to 50% cases. We present an unusual case of adult intussusception which was not diagnosed on any investigation including computerized tomographic (CT) scan and magnetic resonance imaging (MRI). It was a case of ileo-ileo-cecal intussusception caused by a large lipoma 38 mm × 43 mm × 61 mm. It was treated by emergency laparotomy for acute intestinal obstruction. A conservative resection with ileostomy was performed with good postoperative recovery.
Gastrointestinal duplication is a rare congenital anomaly. Although it usually presents within the first few years of life, it may appear much later as described in this report of a 19-year-old man who had symptoms of gastric outlet obstruction. He was found to have a noncommunicating antral duplication cyst. The cyst was managed by antrectomy with excision of the cyst and several centimetres of duodenum. Microscopically the duplication cyst contained a mucosa, submucosa and muscularis. There was no evidence of ulceration or malignant cells. His recovery was smooth. The etiology, presentation and management of antral duplication cysts causing gastric outlet obstruction are discusssed.
Transmission of the protozoan parasite Giardia lamblia from one to another host individuum occurs through peroral ingestion of cysts which, following excystation in the small intestine, release two trophozoites each. Many studies have focused on the major surface antigen, VSP (for variant surface protein), which is responsible for the antigenic variability of the parasite. By using trophozoites of G. lamblia clone GS/M-83-H7 (expressing VSP H7) and the neonatal mouse model for experimental infections, we quantitatively assessed the process of antigenic variation of the parasite on the transcriptional level. In the present study, variant-specific regions identified on different GS/M-83-H7 vsp sequences served as targets for quantitative reverse transcription-PCR to monitor alterations in vsp mRNA levels during infection. Respective results demonstrated that antigenic switching of both the duodenal trophozoite and the cecal cyst populations was associated with a massive reduction in vsp H7 mRNA levels but not with a simultaneous increase in transcripts of any of the subvariant vsp genes analyzed. Most importantly, we also explored giardial variant-type formation and vsp mRNA levels after infection of mice with cysts. This infection mode led to an antigenic reset of the parasite in that a VSP H7-negative inoculum “converted” into a population of intestinal trophozoites that essentially consisted of the original VSP H7 type. This antigenic reset appears to be associated with excystation rather than with a selective process which favors expansion of a residual population of VSP H7 types within the antigenically diversified cyst inoculum. Based on these findings, the VSP H7 type has to be regarded as a predominant variant of G. lamblia clone GS/M-83-H7 which (re-)emerges during early-stage infection and may contribute to an optimal establishment of the parasite within the intestine of the experimental murine host.
An unusual case of cecal volvulus arising from a strangulating fallopian tube is presented. The etiology, diagnosis, and management guidelines of this infrequent cause of large bowel obstruction are reviewed. Computed tomography images are included, which demonstrate key features that are pathognomonic for this condition. To our knowledge, this is the first report of gynecologic adnexa giving rise to cecal volvulus.
Cecal volvulus; Gynecologic and general surgery; Intestinal obstruction
Torsion of ovarian cyst is a common cause of acute abdomen especially in women of reproductive age-group. It commonly presents with colicky abdominal pain associated with nausea and vomiting. It could however mimic acute intestinal obstruction.
The patient was a 32-year-old multipara with no previous history of pelvic or abdominal surgery. She was admitted with colicky lower abdominal pain associated with repeated episodes of vomiting and nausea. Laboratory investigations were essentially normal. Abdominopelvic USS showed a hypoechoic mass lesion in the left adnexium measuring 7.1 × 5.5 cm; surrounding bowel loops were hypoactive, dilated, and fluid filled. Diagnosis of acute abdomen secondary to suspected torsion of ovarian cyst was made. Management began for acute abdomen with intravenous hydration, prophylactic antibiotics, and analgesics. An emergency laparotomy revealed about 6 cm defect in the left broad ligament in which a 20 cm segment of terminal ileum was encased. Liberation of the ileal segment was done and the broad ligament defect closed.
Bowel obstruction requires high index of suspicion in a patient with acute abdomen due to suspected torsion ovarian cyst most especially in the absence of previous pelvic or abdominal surgery.
Duplication of alimentary tract is one of the rare congenital anomalies. A case of duplication cyst of the cecum, presented in the 3rd month of life, as intestinal obstruction. Excision of the cyst along with cecum and appendix was done. The child had an uneventful postoperative recovery following ileoascending anastomosis.
Caecal duplication cyst; Intestinal obstruction