BACKGROUND Hydatid disease, caused by Echinococcus granulosus, is an endemic parasitic infection that predominantly affects the liver. Although slow-growing and asymptomatic, large hepatic cysts lead to catastrophic vascular complications, including inferior vena cava (IVC) thrombosis and pulmonary embolism (PE). Although rare, life-threatening events require prompt recognition and multidisciplinary management to optimize outcomes. CASE REPORT A 68-year-old woman with paroxysmal atrial fibrillation presented with right upper-quadrant pain, fever, and poor oral intake for several weeks. Examination revealed abdominal distension, hepatomegaly, and mottled, cold lower limbs. Laboratory findings showed severe metabolic acidosis and leukocytosis, indicating significant systemic involvement and possible sepsis. Computed tomography (CT) angiography demonstrated a pulmonary embolism, a giant (29×18 cm) right hepatic cyst exerting a mass effect, and extensive thrombosis extending from the infrarenal IVC to both external iliac veins. Echocardiography showed extrinsic cardiac compression without signs of tamponade but with functional compromise related to mass effect. Management included anticoagulation, albendazole, broad-spectrum antibiotics, vasopressors, and continuous renal replacement therapy. Ultrasound-guided percutaneous drainage of the cyst yielded 4 L of purulent fluid, with transient improvement in limb perfusion suggesting partial decompression of venous outflow obstruction. An IVC filter was inserted, but despite intensive therapy, the patient developed refractory shock and died due to progressive hemodynamic collapse and multiorgan failure. CONCLUSIONS Massive hepatic hydatid cysts can precipitate IVC thrombosis and PE through mechanical compression or infection-related inflammation. Early diagnosis, multidisciplinary coordination, and timely surgical or percutaneous decompression are vital to prevent death.

Heterotopic pancreas (HP) is a rare congenital anomaly characterized by pancreatic tissue lacking anatomical and vascular continuity with the orthotopic pancreas. Although usually asymptomatic and incidentally diagnosed, HP may rarely become clinically significant due to inflammation, ulceration, bleeding, obstruction, or gastrointestinal perforation. Systemic conditions such as amyloidosis, chronic kidney disease (CKD), and chronic hemodialysis may further increase gastrointestinal vulnerability through vascular fragility, impaired mucosal healing, and recurrent splanchnic hypoperfusion. We present the case of a patient with systemic amyloidosis and end-stage CKD on maintenance hemodialysis through a recently created brachial-basilic arteriovenous fistula who developed progressive gastrointestinal symptoms followed by acute abdomen. Initial manifestations included nausea and projectile vomiting one day after fistula creation, followed by progressive right upper quadrant abdominal pain radiating to the lumbar region, semiliquid bowel movements, dehydration, and hemodynamic instability. Imaging studies suggested a perforated viscus with intra-abdominal inflammatory changes. Emergency exploratory laparotomy revealed perforation at the antro-duodenal junction with diffuse fibrinous peritonitis and multiple cystic peritoneal lesions suspicious for malignant disease. Surgical management consisted of segmental gastroduodenal resection, extensive peritoneal lavage, targeted peritoneal biopsies, cholecystectomy, and appendectomy. Histopathological examination demonstrated heterotopic pancreatic tissue associated with ulceration and perforation. Immunohistochemistry of the peritoneal lesions showed positivity for WT1 and calretinin, consistent with benign peritoneal inclusion cysts. This case highlights an exceptionally rare cause of gastrointestinal perforation and underscores the importance of integrating clinical evolution, systemic comorbidities, intraoperative findings, pathology, and immunohistochemistry into surgical decision-making. The coexistence of amyloidosis, CKD, and hemodialysis-related hypoperfusion likely contributed synergistically to mucosal vulnerability and perforation.

This case report highlights the rapid and sensitive diagnostic capabilities of a right upper quadrant (RUQ) ultrasound to diagnose pneumoperitoneum secondary to a hollow viscus rupture. The patient was a 55-year-old male with sudden onset epigastric and right upper quadrant pain. Symptoms were concerning for either acute cholecystitis and gastric ulcer or perforation. Immediate point of care ultrasound (POCUS) of the RUQ showed no signs of acute cholecystitis but showed concerning findings of intraabdominal free air given the enhanced peritoneal stripe sign, reverberation, and ring down artifacts. The radiologist did not note any signs of free air on the interpretation of the formal ultrasound. Eventually, the chest X-ray and computed tomography (CT) of the abdomen and pelvis showed air under the right diaphragm, fluid in the porta hepatis, and multiple foci of pneumoperitoneum. Broad spectrum antibiotics and fluid resuscitation were given. General surgery performed an emergency diagnostic laparotomy with repair of duodenal ulcer perforation. Upper gastrointestinal (GI) study on post-operative day three showed no complications, and patient has been doing well in follow-up clinic visits. In this case report, immediate recognition of signs of pneumoperitoneum would have expedited the treatment and management of the duodenal perforation. Although our emergency department was able to perform a CT scan of the abdomen and pelvis and have it read within two hours, this may not be possible in all emergency departments. Therefore, the use of POCUS in the evaluation of abdominal pain can identify potentially disastrous time-dependent pathology. It would be beneficial for emergency physicians to learn the signs of pneumoperitoneum on ultrasound since this requires emergent surgery.

Ulcerative colitis (UC) is associated with an increased risk of infectious complications, particularly during anti-tumor necrosis factor (anti-TNF) therapy. Pyogenic hepatic abscess is a rare but potentially life-threatening extraintestinal complication of UC. Optimal biologic management following deep infection during anti-TNF therapy remains unclear. Mirikizumab, a selective interleukin-23 p19 inhibitor, may have a more favorable infectious safety profile than anti-TNF agents. We report the case of a 19-year-old woman with pancolitis-type UC who developed persistent fever, worsening diarrhea, hematochezia, and subsequent right upper quadrant abdominal pain during maintenance therapy with adalimumab. Contrast-enhanced computed tomography revealed active colitis complicated by hepatic abscess. Adalimumab was discontinued, and intravenous ceftriaxone plus metronidazole therapy was initiated. After confirmation of infection control and abscess regression, induction therapy with mirikizumab was initiated for active UC. Clinical symptoms rapidly improved, and the patient achieved sustained clinical and endoscopic remission without recurrence of the hepatic abscess during long-term follow-up. This case suggests that mirikizumab can be successfully administered after adequate infection control in a patient with UC complicated by hepatic abscess during anti-TNF therapy. However, larger studies are needed to determine the optimal biologic option as a second-line treatment for patients requiring treatment reintroduction after deep infection.

Acute cholangitis is a potentially life-threatening infection of the biliary tract that usually results from biliary obstruction, most commonly secondary to choledocholithiasis. Although prompt diagnosis and treatment often lead to favorable outcomes, uncommon complications such as pylephlebitis (septic thrombosis of the portal vein) may significantly increase morbidity and mortality. We report the case of a 47-year-old woman with no significant past medical history who presented with right upper quadrant abdominal pain, fever (38.2°C), asthenia, and nausea. Physical examination revealed diffuse abdominal tenderness and mild jaundice. Abdominal point-of-care ultrasound (POCUS) made by the emergency physician on call showed multiple gallbladder calculi with sludge but without visible biliary dilatation. Laboratory evaluation demonstrated an inflammatory syndrome with C-reactive protein of 72 mg/L, normal leukocyte count, total bilirubin of 87 IU/L, and direct bilirubin of 56 IU/L, and cholestatic liver enzyme abnormalities, including alkaline phosphatase (ALP) of 190 IU/L and gamma-glutamyl transferase (GGT) of 108 IU/L. The diagnosis of acute angiocholitis was thus suspected. Abdominal imaging (computed tomography (CT) with contrast) showed intrahepatic and extrahepatic biliary dilatation caused by a distal common bile duct stone, multiple gallbladder calculi, and segment II left portal vein thrombosis consistent with pylephlebitis. A diagnosis of acute cholangitis secondary to choledocholithiasis complicated by pylephlebitis was established. The patient was treated with intravenous (IV) antibiotics, fluid resuscitation, and supportive care, with planned biliary decompression and definitive surgical management. This case highlights a rare but serious vascular complication of biliary stone disease. Clinicians should maintain a high index of suspicion for portal venous involvement in patients with cholangitis and persistent systemic symptoms. Early imaging, timely antimicrobial therapy, and coordinated multidisciplinary management are essential to reduce the risk of severe complications and improve outcomes.

An adolescent boy presented with vague respiratory symptoms and mild right upper quadrant abdominal pain. Following physical examination and radiologic evaluation, including chest radiography and contrast-enhanced CT of the chest and abdomen, concurrent pulmonary and hepatic hydatid disease was diagnosed. The patient underwent a single-stage transthoracic phrenotomy for simultaneous excision of cysts from both organs. The postoperative course was uneventful and the patient was discharged on postoperative day 8, resuming daily activities by postoperative day 10. This case highlights the successful use of a single-stage surgical approach for the management of synchronous pulmonary and hepatic hydatid cysts, an uncommon clinical presentation.

Ectopic thyroid tissue is an uncommon developmental anomaly, and involvement of the hepatobiliary region-particularly near the gallbladder neck or cystic duct-is extremely rare. Such lesions may mimic primary biliary or gallbladder masses, creating diagnostic and therapeutic uncertainty. We report a 50-year-old woman with a 2-year history of intermittent right upper quadrant abdominal pain. Contrast-enhanced CT demonstrated a well-defined hyperdense lesion at the hepatic hilum adjacent to the gallbladder neck, measuring 22 × 14 mm (∼80 HU on non-contrast; 119 HU arterial; 104 HU venous), with indistinct borders from the gallbladder. A biliary or gallbladder-associated tumor could not be excluded, and further evaluation with MRI and PET-CT was recommended. The patient declined additional imaging due to financial constraints and strongly requested operative management. Laparoscopic cholecystectomy with en bloc resection of the hilar lesion was performed. Intraoperative frozen-section analysis and final histopathology revealed benign ectopic thyroid tissue composed of mature, well-differentiated thyroid follicles without atypia. Postoperative thyroid ultrasound showed a normal orthotopic thyroid gland. The patient recovered uneventfully and remained symptom-free at follow-up. Ectopic thyroid tissue adjacent to the gallbladder neck is an exceptionally rare cause of a hilar mass. Surgeons should consider this entity in the differential diagnosis of gallbladder neck or porta hepatis lesions of uncertain origin and rely on histopathology to guide appropriate, conservative management.

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapy by improving survival across multiple malignancies by enhancing antitumor immune responses. However, increasing use of ICIs has been accompanied by a growing spectrum of immune-related adverse events (irAEs). Gastrointestinal irAEs most commonly include colitis and hepatitis, whereas biliary complications remain rare and poorly characterized. ICI-associated cholecystitis is an uncommon entity affecting patients treated with ICIs. It often presents as an acalculous disease and occurs months after therapy initiation. This report describes a case of a 64-year-old woman with lung adenocarcinoma receiving adjuvant pembrolizumab after surgical resection and chemotherapy who developed acute right upper quadrant pain and fatigue during her ninth treatment cycle. Imaging revealed significant gallbladder distension and wall thickening in the absence of gallstones, consistent with acute cholecystitis. Given high operative risk from concurrent ICI-induced adrenal insufficiency and absence of severe inflammatory findings, she was managed conservatively with intravenous fluids, antibiotics, and stress-dose corticosteroids, resulting in clinical improvement. Pembrolizumab was discontinued because of suspected immune-mediated toxicity, and she was discharged with plans for elective cholecystectomy and oncologic surveillance. This case highlights the importance of maintaining a high index of suspicion for biliary irAEs in patients receiving ICIs who present with abdominal symptoms and underscores the need for multidisciplinary management and further studies to guide optimal treatment strategies.

Bile duct injuries following blunt abdominal trauma are rare complications that may go unnoticed during emergency care. Due to edema and inflammation, these injuries can lead to bile duct obstruction, resulting in dilation of the hepatobiliary system and potential perforations. Such cases are medical emergencies that require prompt and effective management. This case report aims to present a rare case of bile duct stenosis secondary to blunt abdominal trauma, managed using a minimally invasive approach. Outcomes following endoscopic retrograde cholangiopancreatography (ERCP) are also described. A 25-year-old male patient was admitted with progressive right upper quadrant abdominal pain, accompanied by nausea, vomiting, jaundice, choluria, and acholic stools, occurring two months after sustaining blunt abdominal trauma in a car accident. The trauma had resulted in liver and pancreatic injuries, which were managed conservatively. Imaging revealed bile duct dilation and an abrupt transition in the caliber of its distal third, suggestive of biliary injury. Due to obstructive jaundice, the patient underwent ERCP, which confirmed significant bile duct stenosis. A biliary sphincterotomy was performed, and a prophylactic pancreatic stent was placed to reduce the risk of post-ERCP pancreatitis. However, the patient subsequently developed acute pancreatitis and hemorrhagic shock. Upper gastrointestinal endoscopy identified bleeding and sclerosis of the duodenal papilla. Endoscopic hemostasis using clips, bile duct drainage, and placement of a biliary prosthesis were performed, resulting in clinical improvement. Seventeen days later, the patient developed hospital-acquired pneumonia with pleural effusion and underwent thoracostomy with closed pleural drainage, along with antibiotic therapy using piperacillin and tazobactam, which resolved the condition. The patient remains under outpatient follow-up, undergoing serial dilation of the bile duct. Bile duct strictures are rare complications of blunt abdominal trauma and can have serious consequences. Therefore, it is essential for healthcare teams to remain vigilant for potential biliary tract involvement in post-traumatic patients, maintaining a high index of suspicion in the presence of clinical deterioration or symptoms of biliary obstruction.

Sigmoid volvulus (SV) is an uncommon cause of intestinal obstruction resulting from axial twisting of the sigmoid colon around its mesenteric base. In the absence of complications, endoscopic detorsion is considered the first-line treatment, whereas urgent surgery is required in cases of perforation, peritonitis, or failed detorsion (1). The "coffee bean sign" (massively dilated sigmoid loop directed to the right upper quadrant) and the "whirl sign" (twisting of mesentery and vessels) are well-established radiological findings of SV (2). By contrast, endoscopic features are less well characterized, and evaluating mucosal ischemia or necrosis endoscopically remains challenging. Completely black mucosa is indicative of full-thickness necrosis, while borderline ischemia may present with variably discolored mucosa, including yellowish and reddish spots. In 2021, Uysal et al. described this finding as the "fallen leaves in autumn" sign, reflecting superficial necrosis with preserved viability of deeper layers. We report the case of an 83-year-old male admitted to the emergency department with abdominal pain and rectal bleeding. Imaging revealed classic signs of SV (Figure 1). During endoscopic detorsion, findings consistent with borderline ischemia were noted: loss of submucosal vascularity and scattered reddish-yellowish dots, some confluent. Areas suspected of complete necrosis displayed black mucosa with a sandpaper-like appearance (Figure 2). The patient underwent surgery for irreversible ischemia (Figure 3) but unfortunately died a few days later due to postoperative complications. This case highlights that the "fallen leaves in autumn" sign may serve as a useful endoscopic descriptor of borderline ischemia in SV, complementing established radiological features.