Open Access Case Report

Multifocal Small Bowel Adenocarcinoma Presenting as Multiple Strictures Mimicking Tuberculosis – A Case Report

V. R. Karthikayan, Anil Kumar Singh

Asian Journal of Case Reports in Surgery, Page 11-18

Aims: This article tries to highlight the importance of suspecting Small bowel adenocarcinoma in a patient with multifocal small bowel strictures in tuberculosis endemic regions like India.

Presentation of Case: A 54 year old male presented with colicky central abdominal pain for 4 weeks. Initial evaluation suggested the possibility of Intestinal tuberculosis. He presented again 2 weeks later with acute intestinal obstruction and was taken up for emergency surgery which revealed multiple non passable strictures in jejunum and ileum which were resected and multiple anastomoses were done. Biopsy revealed multifocal primary small bowel adenocarcinoma without any evidence of predisposing factors for small bowel adenocarcinoma.

Discussion: Acute intestinal obstruction is one of the commonest indications for emergency laparotomies and obstruction secondary to small bowel strictures in the Indian subcontinent is most commonly due to Intestinal Tuberculosis with Crohn’s disease being a distant second entity. Small bowel adenocarcinoma is not only rare but also presents with nonspecific findings making it difficult to diagnose. Surgical resection is the cornerstone of management and standard chemotherapy regimens are still evolving. Small bowel adenocarcinoma most commonly presents as a solitary infiltrating mass and hence our case is very unique in its presentation as multiple malignant strictures in jejunum and ileum. Despite extensive histological and radiological evaluation of our patient, there were no known predisposing factors like Crohn’s disease or polyposis that can explain the multifocal presentation of small bowel adenocarcinoma.

Conclusion: Even with all the latest advancement in the field of diagnostics, preoperative diagnosis of small bowel adenocarcinoma is still uncommon. We are reporting this case to stress the importance of having a differential of small bowel adenocarcinoma in intestinal obstruction patients with multiple strictures of small bowel.

Open Access Case Study

Right Side Diaphragmatic Hernia. – A Case Report

Asma El-Karouachi, Ahmed Elmi Abdirahim, Zouhair Abdeladim, Driss Erguibi, Hajri Amal, Boufettal Rachid, Saad Rifki El-Jai, Chehab Farid

Asian Journal of Case Reports in Surgery, Page 1-4

Congenital diaphragmatic hernia (CDH) is a condition characterized by a defect in the diaphragm leading to protrusion of abdominal contents into the thoracic cavity. Right side diaphragmatic hernia is a rare entity. The surgical incidence remains controversial, particularly for the choice of the surgical approach and technique. The mortality is mainly related to associated injuries.

We report a case of right side diaphragmatic hernia in an 84-year-old man who presented with respiratory distress.

This case highlights rarity of the case and the diagnostic difficulties.

Open Access Case Study

Cholangiocarcinoma of an Ectopic Outlet of the Main Bile Duct at the Duodeno-Jejunal Angle – A Case Report

Erguibi Driss, Ahmed Elmi Abdirahim, Hajri Amal, Hamrerras Issam, Rachid Boufettal, Saad Rifki El-Jai, Farid Chehab

Asian Journal of Case Reports in Surgery, Page 5-10

An ectopic outlet of the common bile duct is a rare congenital disorder of the biliary tract. These abnormalities pose a diagnostic problem, and their clinical presentation is not specific. As patients are usually asymptomatic at early stages, the diagnosis is often incidental and at an advanced stage, when clinical manifestations become noticeable. Imaging tests such as hepatic MRI and CT are essential for positive and differential diagnosis, assessment of extension, and treatment planning.

We report a case of a locally advanced tumour in an ectopic biliopancreatic outlet of the main bile duct at the duodenojejunal angle, in a young patient presenting with clinical cholestasis syndrome. The diagnosis was made by an abdominopelvic CT scan and confirmed by Bili-MRI and a biopsy of a liver nodule in the third segment. The biopsy showed metastasis from adenocarcinoma on extemporaneous examination. A double hepatojejunal and gastrojejunal bypass on a Y-shaped loop and a retrograde cholecystectomy with subhepatic redon drainage were performed. The patient’s postoperative course was uneventful.

In the presence of congenital anomalies, the surgeon must remain vigilant because of the potential for accidents during the operation.

Open Access Case Study

Venous Flap for Dorsum of Foot Soft Tissue Defect: An Apt Alternative for Small Defects with Adjunct Modalities

Pradeoth Mukundan Korambayil, Vinoth kumar Dilliraj, Prashanth Varkey Ambookan

Asian Journal of Case Reports in Surgery, Page 19-26

The utilization of venous flaps for small defects lesser than 4cm has its advantage of preserving the artery in the donor site and providing an adequate soft tissue without much of dissection needed for arterial flaps. In this case series, we discuss the utilization of saphenous venous flap in closure of the dorsal soft tissue defect of the foot.  We utilized hyperbaric oxygen therapy as an adjunct to prevent venous congestion and to provide adequate neo-vascularization for the survival of the flap.

Open Access Case Study

Acute Massive Lower Gastrointestinal Bleeding Secondary to Obstructive Colitis Proximal to Obstructing Cancer of the Sigmoid Colon

Sze Li Siow, Myo Nyunt, Hans Alexander Mahendran

Asian Journal of Case Reports in Surgery, Page 27-32

Introduction: Acute massive lower gastrointestinal bleeding (LGIB) is a rare and serious manifestation of obstructive colitis that requires urgent therapeutic intervention. Here, we report a case of LGIB due to obstructive colitis in an adult patient.

Presentation of Case: A 34-year-old man with large bowel obstruction secondary to sigmoid colon cancer underwent laparotomy and Hartmanns procedure (resection of rectosigmoid colon with a proximal end colostomy). Post-operatively, he had recurrent episodes of severe bleeding from the colostomy that required transfusion of a total of eleven units of packed cells and four units of fresh frozen plasma over the next two days. Urgent oesophagogastroduodenoscopy showed pan gastritis and insignificant superficial gastric erosions. Colonoscopy via the colostomy showed stigmata of recent bleed but failed to identify the exact site of bleeding. Computed tomography angiogram failed to localize the site of bleeding. A re-laparotomy was performed. On-table colonoscopy through the end colostomy followed by completion total colectomy and ileorectal anastomosis was done. The patient recovered uneventfully after the surgery with no further episode of rectal bleeding. Histology findings of the resected colon were compatible with obstructive colitis. He remains well at five  years follow-up with no recurrence.

Discussion: The case highlights the rare occurrence of acute massive LGIB as a life-threatening complication of obstructive colitis. The diagnosis should be considered in patients who present with large bowel obstruction.

Conclusion: A high index of suspicion is key to early diagnosis and an extended resection of the colon is necessary to arrest bleeding.