Lipoma is a universal benign tumour which is uncommon in foot and especially in sole region. It should be considered in the differential diagnosis of foot lesions. A case of lipoma of heel of five years duration in a 48 years old housewife is described in which FNAC was inconclusive. However findings of imaging studies suggested diagnosis of lipoma which was confirmed on histopathological examination of the excised mass. Literature has been reviewed emphasising rarity of site lesion.
A three-year-old female child was admitted to emergency department with a history of accidental fall from six-feet height to ground one day before. According to the parents, the child was asymptomatic initially. She started complaining of pain all over abdomen after four hours of fall, which was generalised in nature. She started vomiting approximately eight hours after initial trauma, which was greenish in colour and non-projectile. There was no history of loss of consciousness, Ear, Nose and Throat (ENT) bleed, haematemesis or melaena.The child was then taken to the nearest doctor who advised ultrasonography of abdomen and pelvis which revealed diffusely oedematous jejunal loops, minimal ascites with internal septation due to duodenal or jejunal perforation. There were signs of generalised peritonitis.On admission to our hospital, 24 hours post trauma, patient was febrile and she looked toxic with signs of dehydration. Physical examination revealed pulse-134 beats/min and blood pressure was 86/66 mmHg. No bruises or other external injuries were noted. Abdominal examination revealed distension of abdomen with tenderness and guarding all over the abdomen. Shifting dullness was present and bowel sounds were absent. Routine blood investigations were done which were within normal limits other than raised total leucocyte count which was 13600/mm 3 and decreased serum sodium which was 130 mmol/lit. Erect X-Ray abdomen showed gas under the diaphragm [Table /Fig-1]. Repeat ultrasonography and Computed Tomography (CT) abdomen was not done due to frank clinical diagnosis and considering the duration of trauma.Patient was planned for emergency explorative laparotomy. Right upper transverse incision was taken considering the age of patient. On exploration abdomen was found to be filled with bilious fluid. There was a single isolated jejunal perforation of size 3×2 cm at antimesenteric border, about 100 cm away from the ligament of Treitz [Table/ Fig-2]. Jejunal loop of 15 cm was found to be gangrenous [Table /Fig-3]. The rest of the bowel and other organs were normal.Resection of gangrenous segment of jejunum and jejuno-jejunostomy was done. Drains were inserted and the abdomen was closed after thorough saline wash. Patient was started on antibiotics as per routine protocol. Postoperatively, drain was removed on fifth day and all sutures were removed on eighth day. The postoperative course was uneventful and the patient was discharged after 10 days.
Out of all internal hernias, Paraduodenal Hernia (PDH) is the variety but in PDH right sided one is not that common. In down syndrome, morgagni hernias are often seen as compared to right PDHs. This is a known case of down syndrome presented with chief complaints of abdominal pain, nausea, vomiting and abdominal distension since 2 days. Patient was surgically managed for the right PDH and later re-explored for adhesive intestinal obstruction on postoperative day 12 and later presented with small bowel obstruction symptoms due to adhesions and hence, relaprotomy for postoperative adhesive obstruction was performed. Right PDH is a rare entity encountered in down syndrome which makes it even rare.
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