Testicular choriocarcinoma is a rare and aggressive variant of non-seminomatous germ cell tumor (NSGCT) with early metastatic spread and dismal prognosis. Early recognition of the diagnosis by elevated β-human chorionic gonadotropin (β-HCG) levels in a young male improves his chances of survival following a radical orchiectomy, which establishes the diagnosis and staging. We report a case of a 21-year old young male presenting with a right groin swelling for 2 months. The clinical history was that of a right inguinal hernia but examination findings suggested a testicular tumor, which was confirmed with an ultrasonograhy and contrast enhanced computed tomography (CECT) of abdomen and scrotum and an elevated β-HCG of 23,559 IU. The metastatic workup was clear and so the patient was taken up for immediate right high inguinal orchidectomy and Lichtenstein tension-free mesh repair. HPE of the postoperative specimen proved a mixed germ cell tumor with choriocarcinoma predominance. Semen analysis and sperm banking were done and the patient was started on chemotherapy and sequential normalization of β-HCG levels was observed. Choriocarcinoma is an aggressive variant of NSGCT with inherent invasive and metastatic potential rapidly metastasizing to the liver, lung, brain, etc. So a thorough knowledge of the varied clinical manifestations of the choriocarcinoma syndrome ensures early detection even when the presentation is misleading. Treatment is directed towards confirming the diagnosis and staging with histopathology examination and postoperative chemotherapy for persistent normalization of the tumor markers.
Intramesenteric internal hernia is a rare type of small bowel mesentery related internal hernia which usually occur in pediatric population. It is characterized by herniation of small bowel loops through a congenital or acquired defect in one layer of the mesentery producing a mesenteric pouch type hernia. The defect usually occurs near the ileocaecal valve or ligament of treitz and the herniated bowel loops are prone to strangulation or volvulus, presenting as small bowel obstruction that warrants early recognition and emergency laparotomy to confirm the diagnosis and prevent bowel gangrene and its complication. We present a case of 59 year old male presenting with features of an acute intestinal obstruction since morning and a vague firm mass in the right upper quadrant which was confirmed by CT scan to be an internal hernia and patient was taken up for emergency laparotomy. Intraoperative findings revealed a sac of small bowel loops herniating into the mesentery through a defect near the terminal ileum. Upon reducing the contents a volvulus was evident and resulted in the gangrene of the small bowel loops. The gangrenous bowel was resected and a single layered end to end ileo-ileal anastamosis was done. The diagnosis of internal hernia in a adult with no previous history of abdominal surgery or trauma is a very rare entity and requires a high degree of suspicion and close monitoring of the patient to ensure early surgical intervention and optimal outcome.
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