Accessory spleen. A diagnostic challenge. Case Study.

Preoperative determination of the accessory spleen still is a major factor in the failure of both laparoscopic and conventional techniques. This study aimed to evaluate the practicability and efficacy of a handheld gamma probe in identifying accessory spleens at the initial intervention. This study evaluated 17 patients undergoing laparoscopic splenectomy attributable to benign hematologic disorders. All the patients had preoperative ultrasonography, computed tomography (CT) scan, and nuclear scintigraphic examination of the abdominal cavity to assess the size of the spleen, and to determine the existence of the accessory spleen or spleens. For all the patients, a handheld gamma probe count was used intraoperatively as an adjuvant method to define the presence and location of the accessory splenic tissue. Control nuclear scintigraphic examinations of all the patients were performed 1 month after the surgical procedure. In two cases, intraoperatively accessory splenic tissue was detected by gamma probe, confirming the preoperative CT findings for the patients. One of these patients had three accessory spleens, although preoperative CT scan showed only two of them. However, by the help of the gamma probe, a third spleen located retroperitoneally was defined. For two patients, laparoscopic exploration and handheld gamma probe count did not identify any accessory splenic tissue, although preoperative CT scan indicated accessory spleens. For detecting accessory splenic tissue, the sensitivities of the studied techniques were 0% for ultrasonography, 75% for CT scan, 0% for preoperative nuclear scintigraphy, 75% for laparoscopic exploration, and 100% for perioperative gamma probe examination. Preoperative imaging methods for accessory spleen determination still have limited benefits because of their limited sensitivity. Thus, the handheld gamma probe technique may be an adjuvant method for laparoscopic exploration ensuring that no accessory splenic tissue is missed during the initial surgical treatment of benign hematologic disorders.

Diagnosis of gastric subepithelial mass as an accessory spleen using fusion of spleen SPECT and CT images

Accessory spleen (AS) is a benign condition, where ectopic spleen tissue can be found elsewhere in the abdomen and pelvis, with approximately 20% of cases located at or in the tail of the pancreas. When discovered on imaging, it can be mistaken for conditions that do require surgical removal, including neuroendocrine tumor, and so accurate diagnosis of AS can prevent unnecessary surgery. Endoscopic ultrasound (EUS)-guided fine-needle aspiration (FNA) is a commonly performed diagnostic modality that can lead to a confirmatory diagnosis of AS. We present a case of AS diagnosed at our institution by EUS-FNA and review the literature for all reported cases of AS that have been confirmed by EUS-FNA.

IntroductionAn accessory spleen (AS), a common condition, is usually located in the hilar region of the spleen. ASs are not often large; however, after splenectomy, the initially inactive AS may become reactive and hypertrophic. Therefore, an AS can be misdiagnosed as a neoplastic tumor and removed unnecessarily. An undiagnosed abdominal mass located in the spleen site in a patient who has had a splenectomy must be managed carefully. Computed tomography (CT) scanning and magnetic resonance imaging (MRI) may provide useful information for the diagnosis, preventing unnecessary surgery. Case presentationHerein, we report the case of a 38-year-old female with an enlargement of AS after splenectomy that was misdiagnosed as a primary tumor of the pancreas and managed by a nonessential surgery. ConclusionAn AS should be added to the differential diagnosis of a pancreatic tail tumor for patients with prior splenectomy in order to avoid nonessential surgery to ensure the patient’s safety.

Towards improving the reporting quality of clinical case reports in complementary medicine: Assessing and illustrating the need for guideline development

This study aims to assess retrospectively the imaging features of computed tomography (CT) and clinical characteristics of epidermoid cyst in intrapancreatic accessory spleen (ECIPAS). Seven consecutive patients with pathologically confirmed ECIPAS were included. CT images and clinical data were analyzed. The CT features emphasized included the location, size, calcification, cystic features, surrounding accessory spleen, density, and enhancement of the lesions. Five patients were male and two were female with a mean age of 43.2 years ranging from 25 to 66 years. Most cases were incidentally detected. All lesions were situated in the pancreatic tail, wherein the mean size was 4.4 cm. The cyst appeared unilocular in four cases and multilocular in three cases. An accessory spleen surrounding the cyst was recognized in all seven cases, and the cystic wall of ECIPAS showed a contrast enhancement similar to that of the spleen during multiphasic scans. ECIPAS is an extremely rare entity. The diagnosis of an ECIPAS should be considered when enhancing the cystic wall of the lesion in the pancreatic tail similar to that of the spleen during multiphasic scans.

Introduction and Importance:Rectus sheath hematoma (RSH) is an uncommon and frequently misdiagnosed cause of acute abdominal pain that may mimic more serious intra-abdominal emergencies, including acute pancreatitis.Case Presentation:We present the case of a 62-year-old man who developed a large RSH following a coughing episode, presenting with right-sided abdominal pain and periumbilical ecchymosis (Cullen’s sign). Normal pancreatic enzymes and computed tomography (CT) imaging were key in excluding pancreatitis and confirming the diagnosis of RSH. The patient was managed conservatively with a successful resolution.Clinical Discussion:This case highlights the importance of considering RSH in the differential diagnosis of acute abdomen, even in the absence of anticoagulation, and the critical role of imaging in its timely diagnosis. This case reinforces the value of CT imaging and focused physical examination in differentiating RSH from other causes of acute abdomen.Conclusion:RSH remains a rare but critical diagnostic consideration in patients presenting with acute abdominal pain, particularly when Cullen’s or Grey Turner’s signs are present but pancreatic enzymes are normal. Early diagnosis, facilitated by CT imaging, can prevent unnecessary surgical interventions and guide successful conservative management, thereby improving patient outcomes.

Alimentary tract perforations represent an emergency and life-threatening condition requiring prompt diagnosis and surgical treatment. The clinical diagnosis, particularly in the early stage, is difficult as the symptoms may be variable and nonspecific. The imaging plays an important role to determine the diagnosis and ensure an appropriate treatment to these patients. In this chapter, the diagnostic approach to alimentary tract perforations is discussed focusing on each of the following imaging methods: plain abdominal X-ray, ultrasound (US), computed tomography (CT), and magnetic resonance (MR). Plain abdominal X-ray still remains the most frequently requested imaging examination in the emergency department; the US and CT traditionally have been the dominant cross-sectional imaging modalities for evaluating acute thoracic, abdominal, and pelvic conditions; MR can be useful in the differential diagnosis of acute abdomen in specific patients.

To report use of mandibular condylectomy for treatment of advanced degenerative joint disease of the temporomandibular joint (TMJ) caused by sepsis. Clinical case report. Two-year-old Noriker filly. Computed tomography (CT) was used to confirm advanced degenerative joint disease of the left TMJ and for follow-up after mandibular condylectomy and removal of necrotic meniscus. Painful swelling (3 weeks duration) with drainage located just caudal to the left lateral canthus of the eye was associated with atrophy of the left masseter muscle, masticatory problems, and inappetence. There was incisor malocclusion with a 1.4 cm resting lateral mandibular deviation to the right and inability to open the mouth more than a few centimeters. Left mandibular condylectomy combined with meniscectomy and thorough debridement of the septic left TMJ resulted in resolution of clinical signs and complete return of function. Streptococcus zooepidemicus, intermediately resistant to penicillin and subsequently to enrofloxacin, was isolated from the wound. Regeneration of a mandibular "pseudocondyle" was evident on CT at 4 months. At 4 months and 1 year the filly had maximal mouth opening >10 cm and no malocclusion. Mandibular condylectomy can be used to facilitate management of septic TMJ arthritis. There was no radiologic or clinical evidence of TMJ ankylosis >1 year after meniscal removal. Mandibular condylectomy, including meniscectomy, is an acceptable treatment option for advanced TMJ septic arthritis and allowed return of normal masticatory function.

We present a 48-year-old male patient with a mass in the tail of the pancreas on abdominal ultrasonography. The lesion was suspicious for a well-differentiated pancreatic neuroendocrine tumor and spleen preserved distal pancreatectomy surgery was performed. It was diagnosed as intrapancreatic accessory spleen (IPAS) after pathological examination. Accessory spleen is not an infrequent congenital entity caused by the localization of normal splenic tissue in ectopic regions. As it is known, an accessory spleen is a benign entity and does not require surgical treatment or follow-up when detected. However, it is important to recognize IPAS tissue as it may mimic a pancreatic neoplasia when it is located in the pancreas. In this article, we discuss the differential diagnostic possibilities of the IPAS entity.

Third molars are one of the greatest challenges in oral surgery due to the many different positions these teeth can be found in the dental arch, as suggested by the classifications described by Pell and Gregory, according to MEDEIROS(1) et al. In addition, there are also morphological variations in the number and shape of the roots. This case report aims to provide a preventive approach to the extraction of ectopic third molars, which have a high risk of migrating to other anatomical spaces during surgery, bringing more peace of mind to the dental surgeon's actions in outpatient or inpatient surgeries. After confirming the need through a CT scan, the patient underwent surgery to remove the third molar tooth, following the normal surgical protocols until the tooth was exposed, where a tie wire was used to pierce the tooth after drilling it, to guarantee traction without the possibility of it being pulled into the submandibular space. The surgical procedure was carried out smoothly due to the approach used, and the patient was monitored during and after surgery, with excellent results. We conclude that the strategy used is an efficient method for reducing the occurrence of trans-operative accidents in noble areas of the facial anatomy.

Background: Ruptured endometriotic cysts are a rare but significant cause of acute abdominal pain in women of reproductive age. Prompt recognition and management are crucial to prevent complications and preserve fertility. Case Series: This report presents a series of three cases of ruptured endometriotic cysts in women aged between 25 and 35 years, each presenting with acute abdominal pain. Clinical evaluation, imaging, and surgical exploration confirmed the diagnosis. All patients underwent laparoscopic intervention, which revealed hemoperitoneum and ruptured ovarian endometriomas. Histopathological examination confirmed endometriosis. Postoperative recovery was uneventful in all cases, and patients were managed with hormonal therapy to prevent recurrence. Conclusion: Ruptured endometriotic cyst should be considered in the differential diagnosis of acute abdomen in women of reproductive age, especially those with a history of dysmenorrhea or endometriosis. Laparoscopy remains a valuable diagnostic and therapeutic tool in such cases.

Introduction and Importance:Meckel’s diverticulum (MD) is the most common congenital anomaly of the gastrointestinal tract, typically asymptomatic but occasionally presenting with complications such as bleeding, obstruction, or rarely, perforation. Symptomatic MD is unusual in the elderly, often mimicking other acute abdominal conditions and posing diagnostic challenges, especially in low-resource settings.Case Presentation:We report a case of a 64-year-old male presenting with a 2-day history of right iliac fossa pain, fever, nausea, and vomiting. Clinical examination and laboratory findings were suggestive of perforated appendicitis. Due to the unavailability of CT imaging, an urgent exploratory laparotomy was performed, revealing a perforated MD located 40 cm from the ileocecal valve. A wedge resection was conducted. Histopathological examination confirmed ischemic necrosis and ectopic gastric mucosa. The patient recovered smoothly and was discharged on postoperative Day 5.Clinical Discussion:Perforation of MD is rare, particularly in elderly patients, and often leads to diagnostic confusion with more common causes of acute abdomen. In the absence of reliable imaging modalities, clinical acumen and timely surgical exploration are crucial. The presence of ectopic gastric mucosa within MD increases the risk of perforation. Surgical resection, tailored to intraoperative findings, remains the definitive treatment.Conclusion:This case underscores the need to consider MD in the differential diagnosis of acute abdomen, even in older adults. In resource-limited settings, prompt surgical intervention guided by clinical evaluation can be lifesaving and highlights the importance of maintaining a broad differential to avoid missed or delayed diagnoses.

Background Buccal space tumors constitute rare pathologies with significant histological diversity. They may pose serious diagnostic and therapeutic challenges for the head and neck surgeon. Methods A case of buccal space tumor diagnosed and treated in a tertiary center is presented. Clinical presentation, imaging, and surgical approach are discussed, followed by review of the literature. Results A 79-year-old male patient with a slowly growing painless mass on the right cheek presented to a head and neck reference center. Imaging revealed a tumor of the right buccal space with nonspecific characteristics. Imaging studies revealed extended infiltration of the masseter muscle as well as the anterior border of the parotid gland. FNA biopsy was performed but was nondiagnostic. The decision of surgical excision with a modified parotidectomy incision was taken. The lesion was completely excised with preservation of neighboring facial nerve branches and ipsilateral Stensen's duct. The postoperative course was uneventful. Histological examination showed CLL/Lymphoma, and the patient was referred to the hematology department for staging and further management. Conclusion Differential diagnosis of buccal space masses is very diverse. Despite challenges in the diagnostic and therapeutic approach, these entities may be managed surgically with minimal morbidity.

Objective: Vasculitides are a group of rare, systemic diseases that induce inflammatory reactions in blood vessels, causing a reduction of blood flow and ischemia. In the kidney, luminal narrowing reduces blood flow and activates the renin-angiotensin-aldosterone system, causing renovascular hypertension. Design and method: Clinical case report. Results: A 47-year-old male with previous intestinal tuberculosis and hypertension diagnosed two years prior (blood pressure around 220/110 mmHg) was referred to our Hypertension Clinic. He reported self-limited episodes of lumbar pain, tender erythematous nodules in the shins and arthralgias. His mean office blood pressure was 203/118 mmHg, confirmed in home blood pressure monitoring, without medication. He had left ventricular concentric hypertrophy and chronic kidney disease (eGFR 66 mL/min/1.73m2) with albuminuria (561 mg/24 h). Verapamil and clonidine were prescribed to search for secondary hypertension but he missed the following appointment. A few months later he was admitted to the Intensive Care Unit due to a hypertensive emergency, with acute kidney failure and a large peri-renal hematoma. A CT scan and an angiography showed bilateral renal scarring, intrarenal pseudoaneurysms and small irregularities in the renal arteries. The immunologic panel was negative. A PET scan showed a slight enhancement of the aorta walls and common carotid arteries and the diagnosis of large-vessel vasculitis was established. He was discharged with high-dose corticosteroids and lisinopril and returned to our Hypertension Clinic. His blood pressure remained uncontrolled despite full-dose amlodipine, chlorthalidone and nebivolol; lisinopril was stopped due to worsening kidney function. Due to doubts on the diagnosis, the CT scan was repeated, now showing also irregularities in the common hepatic artery and mesenteric artery, suggesting a medium-vessel vasculitis, namely polyarteritis nodosa, and cyclophosphamide was started. His blood pressure is now controlled with lisinopril 2.5 mg, amlodipine 10 mg bid, furosemide 40 mg bid, nebivolol 5 mg and clonidine 0,15 mg tid and his kidney function is stable. Conclusions: Renovascular hypertension is responsible for less than 1% of all cases of hypertension and, when present, it is usually caused by atherosclerotic disease or fibromuscular dysplasia. However, in more infrequent cases, an inflammatory systemic disease may be present and must be considered.