DESCRIPTIONChildren with hydrocephalus are commonly treated with a ventriculoperitoneal (VP) shunt for diversion of CSF. Unfortunately, complications arising from VP shunting are not uncommon. Apart from shunt blockage and infection, it may become disconnected or fractured and migrate into the potential spaces or viscera.Here we present images of a unique complication of VP shunt in a 14-year-old boy who had a background history of congenital hydrocephalus. At the age of 13 years, he had a fracture of the right VP shunt at the mid-cervical spine level ( figure 1A) with migration of the distal portion into the abdomen. Revision of the right VP shunt was done but the previously migrated distal tube was not removed from the abdomen as the patient had no abdominal symptoms. However, 7 months later he presented with a 3 day history of left scrotal swelling and fever. On examination, the left scrotum was red, swollen and tender, with a palpable foreign body within.The abdominal radiograph ( figure 1B) and scrotal ultrasound (figure 2) show the presence of the previously fractured distal portion of the VP shunt in the left scrotum. Intraoperatively, a patent narrow inguinal canal was detected paving the tract for the migration. Successful removal of the tube by left herniotomy was performed with an uneventful recovery.VP shunt fracture and migration into the scrotum is a very rare phenomenon.1 This complication tends to occur in younger children because of the higher incidence of an unobliterated processus vaginalis and smaller volume of the peritoneal cavity.1 Figure 1 Images of the frontal (A) neck/chest and (B) abdominal radiographs. The neck/chest radiograph demonstrates the initial site of the fractured right ventriculoperitoneal (VP) shunt at the upper cervical region (arrowhead). The abdominal radiograph was taken 7 months later after the revision. The coiled distal portion of right VP shunt had migrated into the left scrotum (curved arrow). The tip of the right shunt was seen in the lower abdomen (black arrow) while the tip of the left shunt was seen in the left upper abdomen (white arrow). There was no evidence of intestinal obstruction. Right hip dislocation was also seen.

Inguinal scrotal swelling is a common presentation to surgical clinic with various differential diagnoses. In most circumstances, a good clinical assessment is sufficient to identify the diagnosis. Imaging is necessary when diagnostic difficulty was encountered. The choice of imaging study could affect the management and outcome. A 60-year-old male presented with an enlarging right inguinal scrotal swelling for 5 years. Clinical examination showed a swelling extended from the right inguinal region down to the right scrotum, firm, not reducible, and not separable from the right testis. Differential diagnoses range from the malignant testicular tumor, irreducible inguinal hernia to the soft-tissue tumor. Ultrasonography and computed tomography scan were unable to conclude the origin of the tumor and involvement of the right testis. Inguinal exploration with potential radical orchiectomy was planned and caused much distress to the patient, resulted in delay in surgery. Intraoperatively, the mass was separated from the testis and spermatic cord, and thus, excision biopsy was performed sparing the testis and spermatic cord. Histopathological examination showed cellular angiofibroma. The right choice of imaging modality is important to provide a precise diagnosis and better treatment plan. This could avoid the unnecessary distress to the patient for potential organ lost. A review through the literature showed the ability of magnetic resonance imaging to better delineate the anatomy of inguinal scrotal soft-tissue mass and thus should have been the imaging modality of choice.

Endometriotic cysts a common benign gynaecological disease in women of reproductive age. We report an unusual case of ruptured endometrioma associated with increased CA 19-9. A 27-year-old woman presented with an acute abdomenal adnexal mass and elevated CA 19-9. The initial diagnosis of ovarian malignancy turned out to be a ruptured endometrioma, confirmed during surgery and in the histopathological report.

Primary umbilical endometriosis (PUE) is a rare gynaecological disorder. A majority of the reported cases were treated with surgical excision as medical treatment had been found to be less successful. We reported a case of PUE successfully treated with dienogest without any profound side effects from the drug.

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