Search

Introduction and Importance: Li-Fraumeni syndrome (LFS) is a rare hereditary disorder caused by mutations in the TP53 gene, leading to a significantly increased risk of developing various cancers at a young age, including breast cancer., Clinical Presentation: This case report details the clinical journey of a 21-year-old female diagnosed with Grade 3 invasive ductal carcinoma, which was estrogen receptor low positive and progesterone receptor negative but positive for Her2 (3+) with a high Ki67 proliferation index., Clinical Discussion: Genetic testing confirmed a TP53 mutation, establishing the diagnosis of LFS. The patient underwent neoadjuvant chemotherapy with TCHP (docetaxel, carboplatin, trastuzumab, pertuzumab), resulting in a complete clinical response. This was followed by bilateral skin-sparing and nipple-sparing mastectomy with sentinel lymph node biopsy and immediate reconstruction. Postoperative pathology confirmed a complete response to neoadjuvant therapy. The patient's treatment plan includes 12 cycles of trastuzumab and pertuzumab, with regular echocardiograms to monitor cardiac function and fertility preservation strategies involving monthly Lupron injections. Given the association of LFS with a high risk of multiple primary cancers, a rigorous surveillance strategy is essential. The psychological impact of a cancer diagnosis and the burden of living with a hereditary cancer syndrome were significant, necessitating comprehensive psychosocial support., Conclusion: Managing Li-Fraumeni syndrome (LFS) and its associated cancers, particularly in young patients, necessitates a comprehensive and multidisciplinary approach. Early genetic testing for TP53 mutations is crucial in identifying LFS, enabling personalized treatment plans and proactive surveillance strategies., Competing Interests: Conflict of interest statement All authors do not have financial or personal relationships with other people or organizations that could inappropriately influence (bias) this work., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Cardiopulmonary resuscitation (CPR) is a critical intervention for cardiac arrest but can result in significant internal injuries due to the force of chest compressions. Among these, subcapsular hepatic hematoma is a rare and serious complication. Here we present a 55-year-old male with a history of alcohol abuse presented with a severe ischemic stroke and subsequently required CPR due to pulseless ventricular tachycardia. Following resuscitation, the patient developed a subcapsular hepatic hematoma, likely caused by the trauma of chest compressions. The patient also had a complex clinical course involving hemorrhagic conversion of the stroke and the need for anticoagulation due to bilateral pulmonary emboli, which further complicated the management of the hepatic hematoma. The identification of the hematoma was achieved through contrast-enhanced CT imaging after the patient exhibited worsening abdominal discomfort and signs of internal bleeding. The management focused on balancing the need for anticoagulation with the risks of further bleeding from the hematoma. A multidisciplinary approach was essential, involving close monitoring, potential surgical intervention, and careful adjustment of anticoagulant therapy. This case emphasizes the importance of recognizing the potential for internal injuries following CPR, especially in patients requiring anticoagulation. Early detection through imaging and a coordinated, multidisciplinary approach are crucial in managing such complications and improving patient outcomes., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Diverticulitis, an inflammation of diverticula in the colon, can lead to severe complications such as perforation and abscess formation. A 42-year-old female with polycystic kidney disease and chronic kidney disease stage III presented with severe abdominal pain, fever, and inability to tolerate oral intake. The patient was a previous smoker who smoked 0.5 packs per day for 25 years. Initial evaluation revealed leukocytosis and elevated creatinine. A CT scan identified pneumoperitoneum and mild sigmoid diverticulitis, suggesting a perforated viscus. She underwent urgent exploratory laparotomy, which confirmed the CT findings and resulted in an appendectomy, sigmoid colon resection, and ostomy creation. Postoperatively, the patient faced complications, including recurrent pneumoperitoneum and subcutaneous emphysema, detected through follow-up CT scans, leading to further surgical interventions. CT imaging was pivotal in diagnosing, monitoring, and guiding treatment, with noncontrast CT being beneficial given her renal impairment. Early diagnosis and CT imaging are crucial in managing complicated diverticulitis. Postoperative monitoring with CT scans is essential for detecting complications. Follow-up care should include regular colonoscopies to assess diverticular disease and dietary modifications to prevent recurrence. Combining clinical, surgical, and radiologic data ensures effective management and improves patient outcomes., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Breast trauma in elderly patients with multiple comorbidities can result in severe complications such as hemorrhagic shock due to the highly vascular nature of breast tissue. This case involves a 65-year-old female with a history of rheumatoid arthritis and prior breast cancer who developed a significant breast hematoma following a motor vehicle accident. Initially stable, she rapidly deteriorated with hypotension and altered mental status after imaging revealed a large hematoma with active hemorrhage. Immediate intervention, including blood transfusion and intubation, was essential for stabilization. While spontaneous cessation of bleeding and hematoma stabilization can negate the need for further intervention, persistent bleeding requires prompt action. Options include surgical exploration, hematoma evacuation, vessel ligation, interventional radiology for embolization, additional blood transfusions, and pharmacological hemostatic agents. Breast hematoma can lead to hemorrhagic shock if severe enough in elderly patients with reduced physiological reserve., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Introduction and Importance: In the complex field of cardiac care, managing patients with severe aortic stenosis, coronary artery disease, aortic aneurysm, and left ventricular dysfunction poses significant challenges. Traditionally, such conditions demand highly invasive surgeries, like open-heart surgery with prolonged cardiopulmonary bypass, increasing the risk of complications and the need for mechanical circulatory support., Case Presentation: This case report details a management of a 53-year-old with no significant past medical history who presented with a three-month history of progressive exertional dyspnea, mixed aortic valve disease, comprising severe aortic regurgitation and moderate aortic stenosis, in addition to coronary artery disease and left ventricular dysfunction.", Clinical Discussion: The patient was deemed to be high risk for conventional open-heart surgery due to his severely reduced ejection fraction and the likelihood of requiring prolonged cardiopulmonary bypass (CPB) and postoperative mechanical circulatory support. Given these considerations, a decision was made to pursue a less invasive transcatheter valve replacement and coronary intervention, avoiding traditional surgery's risks., Conclusion: This approach significantly improved cardiac function and aneurysm stability, demonstrating the potential of minimally invasive techniques in managing complex cardiac conditions., Competing Interests: Conflict of interest statement All authors declare that there are no financial or personal relationships with other people or organizations that could inappropriately influence (bias) this work., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Introduction and Importance: Pneumoperitoneum, the presence of free air in the peritoneal cavity, is typically a concerning finding, often associated with gastrointestinal perforation. However, in peritoneal dialysis (PD) patients, pneumoperitoneum can occur without such severe underlying pathology, frequently due to air entering during dialysis exchanges., Case Report: This case report discusses a 64-year-old male with end-stage renal disease (ESRD) on PD who presented with abdominal pain and distention. The patient reported an incident during a PD session where his dialysis bag became unusually filled with air, coinciding with the onset of symptoms. CT imaging revealed significant free intraperitoneal air, initially raising concerns for gastrointestinal perforation. However, the absence of acute symptoms and stable clinical presentation indicated a nonpathological cause. The patient underwent bedside aspiration of the pneumoperitoneum, resulting in immediate symptom relief., Clinical Discussion: Pneumoperitoneum in a PD patient requires careful evaluation to differentiate nonpathological causes from serious conditions. Accurate diagnostic assessment is crucial, and conservative management can be effective in many cases. Ensuring proper PD techniques and educating patients are key to preventing recurrence., Conclusion: In this case, bedside aspiration was performed to relieve the patient's symptoms, demonstrating a straightforward and effective approach to managing symptomatic pneumoperitoneum., Competing Interests: Declaration of competing interest All authors declare that there are no financial or personal relationships with other people or organizations that could inappropriately influence (bias) this work., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Mucinous neoplasms of the appendix, including low-grade appendiceal mucinous neoplasms (LAMNs), are rare but significant due to their potential for peritoneal dissemination. These tumors are often discovered incidentally during imaging or surgery for unrelated conditions. The presence of mucinous material in the peritoneum raises concern for pseudomyxoma peritonei, necessitating careful intraoperative and postoperative management. A 52-year-old male presented with testicular pain, leading to a diagnosis of seminoma. Staging computerized tomography (CT) revealed a dilated appendix with a surrounding fluid collection, suggestive of a ruptured mucocele. Exploratory laparotomy uncovered a large mucinous mass encasing the appendix, with mucinous deposits in the peritoneum. Final pathology confirmed an invasive mucinous adenocarcinoma, well-differentiated, arising in the background of a low-grade mucinous appendiceal neoplasm. The invasive component extended into the subserosa (pT3), while the LAMN component involved the serosa (pT4a). When mucin is found intraoperatively, surgeons should consider appendectomy with possible conversion to an open approach for thorough exploration. Emergency HIPEC is unnecessary; instead, it should be planned electively after complete cytoreduction. The prognosis depends on the extent of the disease and the success of cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (HIPEC)., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Louis et al.)

Adenosquamous carcinoma of the pancreas (ASCP) is a rare and aggressive variant of pancreatic cancer, characterized by both adenocarcinoma and squamous cell carcinoma components. It presents significant diagnostic and therapeutic challenges due to its atypical histology and poor prognosis. A 72-year-old male presented with abdominal pain, lighter-colored stools, and intermittent nausea. Initial imaging revealed a complex mass in the distal pancreatic body and tail. Elevated lipase levels and subsequent endoscopic ultrasound-guided fine-needle biopsy (EUS-FNB) suggested an atypical pancreatic lesion with keratinizing squamous cells. Further investigation through fiberoptic bronchoscopy and EBUS-guided transbronchial needle aspiration (TBNA) confirmed carcinoma with squamous differentiation. Genetic testing identified KRAS G12D and PIK3CA mutations. The multidisciplinary tumor board recommended systemic chemotherapy with mFOLFIRINOX and G-CSF support. The patient underwent twelve cycles of mFOLFIRINOX with dose adjustments for thrombocytopenia and effective management of chemotherapy-related side effects. Restaging CT scans showed a decrease in tumor size and stable metastatic nodes. The patient showed a partial biochemical response with decreasing CA 19-9 levels and disease stabilization on imaging. This case demonstrates the critical role of a multidisciplinary approach in managing rare pancreatic malignancies. ASCP requires a comprehensive diagnostic and therapeutic strategy involving advanced imaging, histopathological confirmation, and personalized chemotherapy. Integrating advanced diagnostic techniques, molecular profiling, and a multidisciplinary approach is essential for improving patient outcomes and providing comprehensive care for this challenging malignancy. Addressing the psychological aspects and offering compassionate care are vital for supporting patients through their treatment journey., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Noise and distractions in the operating room (OR) critically impact surgical performance and patient outcomes, particularly in high-stakes environments such as trauma surgery. While historical hospital environments prioritized quiet to facilitate recovery and reduce stress, contemporary ORs, especially those handling trauma cases, face increasing noise challenges due to advanced surgical instruments, alarms, and staff conversations, often surpassing federal exposure limits. This review investigates OR noise sources, including staff activities and equipment, analyzing their effects on cognitive load, communication, and error rates among healthcare workers. It identifies high-risk scenarios and vulnerable groups, highlighting the necessity for targeted interventions. Key strategies include implementing strict noise control policies, using noise-reducing materials in OR design, and educating staff on noise impacts. Additionally, structured communication protocols and continuous monitoring systems are advocated to enhance operational efficiency and safety. Surgeon leadership is pivotal in balancing assertiveness and empathy to maintain a productive team dynamic. Furthermore, surgeons significantly boost OR efficiency and safety by adopting these protocols, promoting inclusive team dynamics, and applying noise-reduction strategies. These practices safeguard patient care and foster a more collaborative work atmosphere, aligning all team efforts toward optimal patient outcomes. This holistic approach emphasizes the need for continuous improvement and adaptability in surgical practices to meet modern healthcare demands, particularly in trauma surgery's fast-paced, unpredictable realm. Collectively, these measures can enhance patient safety and improve conditions for surgical teams, providing a framework for quieter, more focused OR environments that ultimately elevate surgical outcomes and healthcare quality., Competing Interests: Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Louis et al.)

Background: In the context of surgical education reform, the integration of residency programs represents a significant milestone. Concerns about potential disruptions to patient care metrics amid these changes necessitate empirical investigation., Methods: This study assessed the impact of integrating surgical residency programs on patient outcomes within Trauma and Acute Care Surgery services. Pre- and postintegration data were meticulously analyzed to evaluate key metrics, including length of hospital stay, recovery rates, and complication rates., Results: Contrary to initial concerns, the introduction of residency programs did not yield significant alterations in patient care metrics. Analysis revealed consistent outcomes pre- and post-integration, indicating the resilience of patient care amidst educational reforms. Despite the introduction of a high-stakes training environment, patient outcomes remained stable., Conclusion: The study highlights the compatibility of educational advancements with the preservation of optimal patient care standards in Trauma and Acute Care Surgery services. Demonstrating the stability of patient care metrics in the face of educational reforms offers valuable insights for healthcare institutions considering similar initiatives. Overall, these findings contribute to the discourse on the value of surgical residency programs, reinforcing the importance of maintaining high-quality patient care standards while advancing surgical education., (Copyright © 2024 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)

Gallstone ileus is a rare yet significant cause of mechanical bowel obstruction, particularly in elderly patients. This condition arises when gallstones migrate into the gastrointestinal tract through a cholecystoenteric fistula, often due to chronic inflammation. Despite medical advancements, gallstone ileus remains associated with high morbidity and mortality rates due to delayed diagnosis and nonspecific symptoms. The clinical presentation typically includes intermittent nausea, vomiting, abdominal pain, and constipation, which can obscure the diagnosis. Advanced imaging techniques, especially computed tomography (CT), are crucial for identifying key diagnostic features such as pneumobilia, ectopic gallstones, and signs of bowel obstruction. Gallstone ileus should be considered in any case of small bowel obstruction, even if CT imaging is inconclusive, as gallstones can be radiolucent. Indirect clues like pneumobilia and dilated small bowel loops can lead to the diagnosis. Effective management of gallstone ileus requires prompt surgical intervention to remove the obstructing gallstone and restore bowel patency. The primary surgical procedure is enterolithotomy, although additional procedures such as cholecystectomy and fistula repair may be necessary depending on the patient's condition and intraoperative findings. The choice of surgical approach should be individualized, considering the patient's overall health and the specific characteristics of the obstruction. Early recognition and timely surgical management are essential to prevent complications and improve patient outcomes., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal neoplasms of the gastrointestinal tract, frequently characterized by mutations in the KIT or PDGFRA genes. This case report details the complex clinical course of a 71-year-old female with a history of HIV and metastatic GIST presenting with acute abdominal symptoms indicative of perforated viscus. Initial imaging revealed a massive pneumoperitoneum and a large abdominal mass, necessitating immediate surgical intervention. The patient underwent multiple surgeries, including bowel resections and colostomy creation, to address the extensive tumor burden and complications. Postoperatively, she required intensive care management, including mechanical ventilation, vasopressor support, and hemodialysis for acute kidney injury. Pathological examination confirmed metastatic GIST with extensive mesenteric and omental involvement. Immunohistochemical staining was positive for CD117 (c-KIT) and DOG-1. Despite aggressive surgical and supportive measures, the patient's condition highlighted the significant challenges in managing advanced GIST with perforation. This case highlights the importance of a multidisciplinary approach, integrating surgical, medical, and intensive care to optimize outcomes. The prognosis of GIST varies widely, with localized tumors having favorable outcomes following resection, while metastatic cases often face a poorer prognosis despite advances in targeted therapies. This case exemplifies the critical need for personalized treatment plans and ongoing research to improve the management and prognosis of GIST patients., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Duodenal adenocarcinoma is a rare and aggressive gastrointestinal malignancy that frequently presents with symptoms like gastric outlet obstruction and biliary obstruction, leading to delayed diagnosis and challenging prognosis. This case report explores the clinical presentation, diagnostic hurdles, and therapeutic management of late-stage duodenal adenocarcinoma in a 53-year-old woman with no significant prior medical history. The patient presented with severe epigastric pain radiating to the right upper quadrant, nausea, and decreased appetite. Elevated liver enzymes and imaging revealed multiple liver masses and a primary duodenal mass. Biopsies confirmed moderately differentiated adenocarcinoma. Tumor markers were evaluated during the staging phase, showing markedly elevated levels. The patient underwent systemic chemotherapy with FOLFOX but faced complications, including pulmonary emboli and neurological symptoms. Management required a multidisciplinary approach, integrating palliative and supportive care to address symptoms and improve quality of life. The case highlights the necessity of considering duodenal adenocarcinoma when diagnosing persistent gastrointestinal symptoms. It highlights the need for a holistic treatment approach, including tailored chemotherapy regimens and vigilant monitoring of complications. Molecular profiling was crucial in guiding treatment decisions, although MSI, HER2, and PD-1 were negative, and the tumor showed no mismatch repair protein deficiency. This article emphasizes the importance of early integration of palliative care and the value of comprehensive pathological analysis in managing advanced duodenal adenocarcinoma, providing insights into diagnostic and therapeutic strategies for this complex case., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Pelvic carcinosarcoma is an aggressive malignancy with significant diagnostic and management hurdles due to its complex vascularity and potential for extensive local invasion. A 59-year-old female presented with severe abdominal pain and significant weight loss, leading to the discovery of a large, complex pelvic mass through CT scans, MRI, and PET CT, suggesting aggressive malignancy. Initial management included a robotic laparoscopic proximal sigmoid loop colostomy to alleviate obstruction. Significant vascularity led to consultations with Vascular Surgery and subsequent preoperative embolization. Definitive surgery involved a supralevator posterior exenteration for en bloc resection of the vagina, mass, and sigmoid colon, combined with a low anterior resection and an omental J flap in anticipation of potential postoperative radiation therapy. This case underscores the importance of integrated imaging and staged surgical interventions in managing pelvic carcinosarcoma, emphasizing a multidisciplinary approach to optimize outcomes and minimize complications., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Hepatic hemangiomas are commonly benign liver tumors, typically asymptomatic and predominantly located in the right lobe. This case report details an exceptional instance of a left-lobe hepatic hemangioma manifesting as an exophytic, pedunculated mass resembling a gastric tumor. A 77-year-old woman with a history of melanoma presented with a mass incidentally discovered during evaluations for chest pain. Advanced imaging techniques, including computed tomography (CT) and endoscopic ultrasound (EUS), identified this mass as a benign, pedunculated hemangioma extending from the left hepatic lobe toward the gastric fundus. Given the tumor's benign nature and the patient's lack of symptoms, a conservative management approach was adopted. This case emphasizes the importance of accurate imaging and diagnostic assessment in managing atypical hepatic hemangiomas, highlighting the need to carefully consider rare growth patterns and locations in differential diagnoses to avoid unnecessary interventions. Such cases reinforce the complexity of diagnosing and managing unusual presentations of common benign tumors., (Published by Elsevier Inc. on behalf of University of Washington.)

Abdominal pain in patients with significant alcohol use and smoking history presents diagnostic challenges due to overlapping clinical features of complications like acute cholecystitis and peptic ulcers. The unreliable physical examinations of intoxicated patients often complicate accurate diagnosis. We present a case of a 56-year-old male with a history of alcoholism and smoking, who presented to the emergency department with nonspecific abdominal pain. Initial imaging suggested cholecystitis, but due to the patient's intoxication, his physical examination was unreliable. During a laparoscopic cholecystectomy, a perforated prepyloric ulcer was unexpectedly discovered, sealed by the gallbladder. This case highlights the limitations of relying solely on imaging for diagnosing abdominal conditions in intoxicated patients. The intraoperative discovery of the perforated ulcer necessitated a shift in the surgical approach, emphasizing the need for flexibility in surgical planning and a high index of suspicion for other abdominal pathologies in patients with significant lifestyle risks. The successful management of this patient through adaptive surgical techniques and comprehensive postoperative care, including Helicobacter pylori eradication therapy, underscores the importance of maintaining a broad differential diagnosis and readiness to adapt surgical plans. This approach is essential for managing complex cases effectively, ensuring that both the immediate surgical issues and underlying causes are addressed to optimize recovery and prevent recurrence., (Published by Elsevier Inc. on behalf of University of Washington.)

Non-steroidal anti-inflammatory drugs (NSAIDs) are commonly used for their analgesic and anti-inflammatory effects but can lead to serious gastrointes complications. This report illustrates the management of an NSAID-induced penetrating gastric ulcer with subsequent postoperative hemorrhagic cholecystitis. A 68-year-old female with chronic NSAID use presented with epigastric pain and was diagnosed with a penetrating gastric ulcer extending into the retroperitoneum. The surgical management required a shift from a minimally invasive robotic-assisted approach to an open procedure due to unexpected intraoperative findings. The postoperative period was notable for the development of hemorrhagic cholecystitis that was managed with percutaneous transhepatic biliary drainage, highlighting the role of interventional radiology in complex postoperative care. NSAID use significantly increases gastrointestinal risks, leading to complications such as ulcers that may penetrate into adjacent structures, including the retroperitoneum. The management of penetrating gastric ulcers typically involves complex surgical procedures, highlighted in this scenario by the necessity for an antrectomy followed by a Billroth II reconstruction to address the extensive damage and restore gastrointestinal continuity, which is essential for patient recovery. In this case, the development of hemorrhagic cholecystitis postoperatively was effectively managed with a percutaneous transhepatic biliary drain, demonstrating the importance of interventional radiology in managing postoperative complications and the need for a multidisciplinary approach. This case report elucidates the management of NSAID-induced penetrating gastric ulcer that extended into the retroperitoneum, necessitating an antrectomy with Billroth II reconstruction. A gastric ulcer is generally classified as "large" if it exceeds 2 centimeters in diameter. These ulcers pose greater risks of complications such as perforation, penetration into adjacent organs, bleeding, and obstruction, necessitating more complex and comprehensive management strategies. The postoperative complication of hemorrhagic cholecystitis was effectively managed via interventional radiology, highlighting the critical role of minimally invasive techniques in addressing severe postoperative complications., (Published by Elsevier Inc. on behalf of University of Washington.)

Embryonal sarcoma of the liver (ESL) is a rare and aggressive neoplasm primarily affecting children, with its occurrence in adults being exceptionally rare. This case report details the presentation, diagnosis, and management of ESL in a 20-year-old patient, highlighting the challenges and strategic approaches required in managing such atypical presentations. The patient presented with progressive right upper quadrant abdominal pain and significant weight loss, with imaging revealing a large mixed-density mass in the right lobe of the liver. Despite the nonspecific clinical symptoms and normal tumor markers, advanced imaging techniques including MRI and CT scans played a pivotal role in the diagnostic process. The mass exhibited characteristics that led to a differential diagnosis of a possible benign condition; however, the decision for surgical resection was made based on the tumor's rapid growth and potential malignancy suggested by imaging. Histopathological examination postsurgery confirmed the diagnosis of ESL. This case illustrates the importance of considering ESL in the differential diagnosis of rapidly enlarging liver masses in adults, despite its rarity in this age group. The effective management of this case through surgical intervention without prior biopsy, due to the risk of tumor seeding, followed by adjuvant chemotherapy, reflects the critical need for a multidisciplinary approach. The outcomes from this case contribute to the existing knowledge base, providing insights into the complexities of diagnosing and treating adult cases of ESL and affirming the adaptability of pediatric protocols to adult patients., (© 2024 The Authors. Published by Elsevier Inc. on behalf of University of Washington.)

Acute mesenteric ischemia is a critical condition marked by a sudden loss of blood supply to the intestines, often leading to rapid tissue necrosis and severe clinical outcomes if untreated. In the context of hypogammaglobulinemia, an immunodeficiency characterized by decreased levels of immunoglobulins, this vascular emergency becomes even more daunting. Hypogammaglobulinemia can impair the immune system's response to both infection and ischemic injury, intensifying the severity of intestinal damage. This report describes the case of a 52-year-old female with hypogammaglobulinemia who presented with severe abdominal pain. Surgical exploration revealed 100 cm of necrotic small bowel extending from 150 cm distal to the ligament of Treitz to within 10 cm of the ileocecal valve. The necrotic section was surgically removed, and primary anastomosis was performed. This instance highlights the significant impact of immunodeficiency on the progression and management of acute mesenteric ischemia, demonstrating the critical need for early intervention and tailored management strategies, especially in immunocompromised patients, to prevent severe outcomes. The case illuminates the importance of recognizing immunodeficiency as a complicating factor in acute gastrointestinal emergencies, stressing the necessity for prompt and effective medical and surgical interventions to improve prognosis and patient outcomes in complex clinical scenarios., Competing Interests: Human subjects: Consent was obtained or waived by all participants in this study. Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work. Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work. Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work., (Copyright © 2024, Louis et al.)

Hypocomplementemic urticarial vasculitis syndrome (HUVS) is a rare autoimmune disorder characterized by chronic urticaria, systemic vasculitis, and hypocomplementemia, posing significant diagnostic challenges due to its overlap with common conditions and varied systemic manifestations. We report the case of a 36-year-old female with a history of post-birth cerebral hemorrhage and seizure disorder, who presented with abdominal pain, diarrhea, and subtle urticarial lesions. Initial investigations by gastroenterology suggested inflammatory bowel disease (IBD), but persistent symptoms and evolving cutaneous signs prompted further evaluation. A skin biopsy demonstrated leukocytoclastic vasculitis, while serological tests showed hypocomplementemia and positive antineutrophil cytoplasmic antibodies (ANCA), confirming HUVS. The patient's management included high-dose corticosteroids and mycophenolate mofetil, with partial symptom relief. Subsequent introduction of rituximab markedly improved her gastrointestinal and dermatological symptoms, highlighting its effectiveness in treating refractory HUVS. This case emphasizes the necessity for vigilance, interdisciplinary collaboration, and personalized treatment adaptations in managing HUVS., Competing Interests: The authors have declared that no competing interests exist., (Copyright © 2024, Louis et al.)