BACKGROUND:The palmaris longus muscle is considered one of the most anatomically variable muscles in the human body. Localized swelling of the forearm due to hypertrophy of the palmaris longus muscle is rare.CASE PRESENTATION:Here, we report a rare case of a 24-year-old Arab man who presented with a painful mass on his forearm with symptoms of median nerve compression. A full radiological assessment was performed, and he was treated conservatively.CONCLUSION:This case confirmed that a hypertrophied palmaris longus muscle can be the cause of swelling on the forearm and should always be considered in the differential diagnosis. With this report, we aimed to increase awareness regarding the unusual variations of palmaris longus muscle and the importance of using radiological investigations to establish a diagnosis.

Diverticular disease of the colon can cause many complications including strictures, obstruction, perforation, abscess, and less often fistulas communicating with surrounding organs. Colouterine fistula is a rare complication of diverticular disease of the colon. We report a case of colouterine fistula treated conservatively due to multiple associated co-morbidities.

Acute acalculous cholecystitis (AAC) is an acute inflammation of the gallbladder in absence of gallstones. It is a potentially fatal form of acute cholecystitis that usually occurs in critically ill patients. The disease may often go unrecognized due to the complexity of the patient's medical and surgical problems. Recently, there is a reported increase in the incidence of acalculous cholecystitis in outpatients without typical predisposing critical illness. We report a case of congestive heart failure and pulmonary embolism which was diagnosed initially as acaculous cholecystitis discussing the pitfalls of diagnosis of the disease which usually result in under-estimation of the condition in seriously ill patients (appropriate patients) and over-estimation of the condition in the outpatients without typical predisposing critical illness (inappropriate patients).

In the last few years, an increasing number of reports of port-site metastasis from unsuspected gallbladder cancer was published and a lot of concern has been expressed that laparoscopic cholecystectomy might adversely affect the prognosis of gallbladder cancer by increasing the risk of port-site and peritoneal seeding. The best prevention of this complication is early (preoperative) diagnosis of gallbladder cancer but this is not always possible. Cases of gallbladder carcinoma diagnosed or suspected preoperatively should be operated by open surgery rather than by laparoscopic surgery. Conversion to open cholecystectomy is appropriate if cancer is suspected during laparoscopic cholecystectomy. If gallbladder cancer is diagnosed postoperatively on histological examination of the gallbladder specimen, surgical and adjuvant radiotherapy to the trocar sites in association with extended treatment to the gallbladder bed and adjacent areas is advisable.

Intragastric balloons have gained popularity in the management of morbid obesity. Although the procedure of insertion is easy and is generally accepted by patients, a few complications can occur. We report a case of small bowel obstruction caused by spontaneous deflation and forced passage of an air-filled intragastric balloon into the small bowel.

Venous thrombosis is a well-known complication of acute appendicitis, like many other intra-abdominal septic conditions. These events can present peripherally in the form of deep vein thrombosis of the lower extremities, or more centrally as pelvic thrombophlebitis. However, an inferior vena cava thrombus is a less common phenomenon in general and especially rare in patients with no thrombophilic diseases. In this case report, we present a case of acute appendicitis with an IVC thrombus. An approach to the management in such a patient population is discussed.

Locally advanced breast cancer constitutes approximately 10%-20% of the newly diagnosed breast cancers and up to 75% of breast cancers in developing countries. Management of fungating breast cancer is difficult as the majority of patients with this stage of the disease develop distant metastases despite appropriate therapy. The only possible cure is to prevent it with increasing public awareness and education, especially in developing countries where, sadly, we still see this stage of the disease. The case of a 65-year-old lady with fungating breast cancer is presented.

Objective: The purpose of this study is to determine the pattern of presentation of carcinoma of the gall bladder in Saudi patients and to assess the accuracy of diagnostic modalities, namely ultrasound and computerized scan, in detecting the disease, together with an extensive literature review to establish suspicious criteria helping in early diagnosis of this lethal disease.Methods: This is a retrospective study of patients diagnosed to have gallbladder carcinoma at King Fahad Medical City, Riyadh, K.S.A. in the period from January 2007 to January 2010.Results: Six patients were included, 5 females and one male (age range between 58 and 87 years, with a mean age of 73 years. The main presenting symptoms were abdominal pain (83.3%), nausea and vomiting (50%). Two patients were found to be jaundiced (33.3%), an abdominal mass was felt in one patient (16.6 %) and weight loss was seen in 4 patients (66.7%). Liver function test showed abnormal liver enzymes in 3 patients (50%), elevated bilirubin in two patients (33.3%), elevated alkaline phosphatase in 4 patients (66.7%) and low albumin in all patients (100%). Low hemoglobin was observed in 2 patients (33.3%). abdominal ultrasound was suspicious for gallbladder carcinoma in two patients (33.3 %), gallstones and chronic cholecystitis were found in the remaining 4 patients. CT scan was performed in 4 patients and it was suspicious of gallbladder cancer in all of them (100%). It detected evidence of liver invasion and hepatic metastasis in one of the 2 operated cases; however, it failed to detect liver invasion in one of the operated patients who subsequently was proved to have liver invasion on histological examination of the liver resection specimen. Histology confirmed diagnosis of adenocarcinoma in all patients with variable degree of differentiation.Conclusions:The poor prognosis of gallbladder cancer is related to its dissemination capacity and usually late diagnosis due to its non-specific clinical presentation. The traditional routine approach of investigation and management of patients with gallbladder stones which depends mainly on ultrasound as diagnostic modality may delay the diagnosis and waste the chance of early detection of gallbladder carcinoma when curative resection is achievable. We recommend a high index of suspicion in patients with gallstones in presence of a combination of female sex, old age, silent gallstones presenting at late age, and thickened wall of the gallbladder on ultrasonic examination. We also recommend adding more sensitive investigation like CT scan, EUS, and ultrasound-guided aspiration cytology/biopsy to the protocol of investigation of these patients.

Primary hepatic carcinosarcoma is rare, with only few adequately documented cases reported in the literature. We report a case of this rare tumor.

Since Meinhard Classen performed the first endoscopic retrograde cholangiopancreatography (ERCP) in 1973, this procedure is gaining more and more popularity in diagnosis and treatment of biliary and pancreatic diseases. ERCP is widely regarded as safe, but the major complication rate approaches 10%. Common complications include pancreatitis, bleeding, cholangitis, and perforation. ERCPrelated perforations occur in about 1% of patients and this injury carries a death rate of 16% to 18%. Tension pneumothorax complicating ERCP has been reported but is a rare occurrence. We report a case of right side tension pneumothorax complicating an ERCP in a 65-year-old lady who had an ERCP for common bile duct stones. We also review the literature for the different options available for management of common bile duct stones and their risks.

Abdominal cocoon, also referred to as sclerosing encapsulating peritonitis, is a relatively rare cause of intestinal obstruction. Pre-operative diagnosis depends on a high index of suspicion. Physicians should be aware of the condition to avoid “surprise" upon laparotomy and to manage cases in a proper way.CT scan is the most helpful tool of investigation. Treatment consists of excision of the accessory peritoneal sac with lysis of the inter-loop adhesions. Bowel resection is unnecessary unless a nonviable segment is found.