Granulomas are a well recognised entity in gastrointestinal surgery. These are mainly foreign body granulomas (formed in response to a foreign irritant, such as a suture material from a prior surgery, talc, contrast material) and immune granulomas (in chronic inflammation). On histopathology, the foreign body giant cell reaction contains multinucleate giant cells with nuclei that are distributed through the eosinophilic cytoplasm, in which the culprit foreign material may often be evident. Here we present an interesting case of a distal ileal obstruction and perforation due to a foreign body granuloma in a male with no prior history of surgery or even endoscopy where no definitive inciting foreign body could be isolated on histopathology, leaving the cause of his foreign body reaction to remain a mystery.

Introduction: Acute appendicitis is essentially a clinical diagnosis, and there are many places in India where confirmation based on radiological imaging is not available immediately. In such scenarios, clinical scoring system comes handy. Materials and Methods: This paper is based on a study to compare the sensitivity and specificity of Raja Isteri Pengiran Anak Saleha Appendicitis (RIPASA) Scoring System and Alvarado Scoring System in the clinical diagnosis of acute appendicitis. There is very little literature about RIPASA Scoring System. Results: The Alvarado Scoring System showed that 6%–12.5% of patients had total score of 5–6 (possible), 31%–64.6% had total score of 7–8 (probable) and 11%–22.9% had total score of 9–10 (very probable). Forty-two patients had a total score of ≥7, which is the cut-off score to be considered for confirming appendicitis. RIPASA Scoring System showed that 43%–89.6% of patients had cut-off score >7.5 (suggestive of appendicitis) and only 5%–10.4% of patients had score <7.5 (other causes). Conclusions: RIPASA Scoring System was more sensitive and specific than Alvarado Scoring System in the clinical diagnosis of acute appendicitis.

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Epidermal cysts are congenital lesions that originate from embryonal tissue remnants. It requires histopathology for its diagnosis. In this case, we report a young male with no comorbidities presenting with perianal swelling. He was evaluated and taken up for surgery. Post operative period was uneventful and he was discharged on 2nd post operative day. He is doing well at 4 months of follow up.

Systemic metastases to primary tumors involving the brain are uncommon. Tumor-to-tumor metastasis involving meningioma from carcinoma breast is very rare. Neuroimaging may suggest the diagnosis—these are neither sensitive nor specific. Thus, the only way to diagnose it is through tissue biopsy.