Dilated Bowel Research Articles

Para-duodenal hernia: a report of five cases and review of literature

BackgroundPara-duodenal hernia (PDH) represents rare clinical entities based on few literatures.Case presentationWe report five cases of Para-duodenal hernia, all occurring in male patients ranging from 34 to 75 years of age. The patients had varied manifestations presenting with abdominal pain with or without vomiting and nausea and with or without signs of intestinal obstruction. CT images showed cluster of dilated bowel segments with displaced mesenteric vessels at hernial orifice. Laparoscopic surgical approach was adopted, and the patients were discharged about a week later without further complications.ConclusionWe hope to raise awareness about the management of this rare clinical entity and the benefits of CT imaging and laparoscopic surgery as standard approaches.

Internal hernia caused by a free intraperitoneal staple after laparoscopic appendectomy

Background: Laparoscopic appendectomy is the gold standard for treatment of appendicitis. Stapled closure of the appendiceal stump is commonly performed and has several advantages. Few prior cases have demonstrated complications from free staples left within the abdomen after the stapler has been fired.Case report: A 29-year-old female underwent laparoscopic appendectomy for acute uncomplicated appendicitis during which the appendix and mesoappendix were divided using laparoscopic gastrointestinal anastomosis (GIA) staplers. Her initial recovery was uncomplicated. She returned on postoperative day 17 with sharp mid-abdominal pain, obstipation, and emesis. Her abdomen was distended, and she had a mild leukocytosis. Computed tomography (CT) demonstrated twisted loops of dilated small bowel in the right lower quadrant with two transition points, suggestive of internal hernia with closed loop bowel obstruction. Diagnostic laparoscopy was performed through the three prior appendectomy incisions. An adhesion between the Veil of Treves and the mesentery of the ileum caused by a solitary free closed staple, remote from the staple lines, had caused an internal hernia. The hernia was reduced, and the small bowel was noted to have early ischemic discoloration. The adhesion was lysed by removing the staple from both structures. The compromised loops of bowel began to show peristaltic movement and color returned to normal, and the procedure was concluded without resection. She was discharged home the following day.Conclusions: Gastrointestinal staplers are commonly used due to ease of use and low complication rate. It is not uncommon to leave free staples in the abdomen as retrieval can be difficult and time consuming. Our case is only the second in the literature reporting an internal hernia with closed loop bowel obstruction as a complication of retained staples. Choosing the most appropriate size staple load to reduce the number of extra staples, removing free staples, or the use of an endoloop can prevent potentially devastating complications.

AAA and dilated bowel loops

AAA and dilated bowel loops

Laparoscopic Management of Strangulated Broad Ligament Hernia

Introduction: Broad ligament hernia was first reported post-autopsy by Quain in 1861. In a 1995 review article, only 61 cases had ever been reported. This paper presents a case report of broad ligament hernia and explores the literature surrounding this topic. Case Presentation: The patient presented with no significant past medical history, acute lower abdominal pain (several hours), nausea, and vomiting. Clinical examination showed a heart rate of 85 beats per minute; normal temperature, blood pressure, and respiratory rate; and a mildly distended abdomen with tenderness across the right lower quadrant. A plain abdominal X-ray showed dilated small bowel loops, and a blood test showed leukocytosis. Urgent diagnostic laparoscopy showed a broad ligament strangulated hernia with small bowel infarction. Reduction of the small bowel, resection, and side-side anastomosis were performed. The patient had an uneventful recovery, and follow up reported no postoperative complications. Conclusion: Laparoscopic management of small bowel obstruction due to broad ligament internal hernia is a safe and effective option.

Short bowel mucosal morphology, proliferation and inflammation at first and repeat STEP procedures

BackgroundAlthough serial transverse enteroplasty (STEP) improves function of dilated short bowel, a significant proportion of patients require repeat surgery. To address underlying reasons for unsuccessful STEP, we compared small intestinal mucosal characteristics between initial and repeat STEP procedures in children with short bowel syndrome (SBS). MethodsFifteen SBS children, who underwent 13 first and 7 repeat STEP procedures with full thickness small bowel samples at median age 1.5 years (IQR 0.7–3.7) were included. The specimens were analyzed histologically for mucosal morphology, inflammation and muscular thickness. Mucosal proliferation and apoptosis was analyzed with MIB1 and Tunel immunohistochemistry. ResultsMedian small bowel length increased 42% by initial STEP and 13% by repeat STEP (p=0.05), while enteral caloric intake increased from 6% to 36% (p=0.07) during 14 (12-42) months between the procedures. Abnormal mucosal inflammation was frequently observed both at initial (69%) and additional STEP (86%, p=0.52) surgery. Villus height, crypt depth, enterocyte proliferation and apoptosis as well as muscular thickness were comparable at first and repeat STEP (p>0.05 for all). Patients, who required repeat STEP tended to be younger (p=0.057) with less apoptotic crypt cells (p=0.031) at first STEP. Absence of ileocecal valve associated with increased intraepithelial leukocyte count and reduced crypt cell proliferation index (p<0.05 for both). ConclusionsNo adaptive mucosal hyperplasia or muscular alterations occurred between first and repeat STEP. Persistent inflammation and lacking mucosal growth may contribute to continuing bowel dysfunction in SBS children, who require repeat STEP procedure, especially after removal of the ileocecal valve. Level of evidenceLevel IV, retrospective study.

Clinical implications of CT findings in mesenteric venous thrombosis at admission

PurposeThe main aim of this study was to evaluate the association of computed tomography (CT) findings at admission and bowel resection rate in patients with mesenteric venous thrombosis (MVT). It was hypothesized that abnormal intestinal findings on CT were associated with a higher bowel resection rate.MethodsRetrospective study of MVT patients treated between 2004 and 2017. CT images at admission and at follow-up were scrutinized according to a predefined protocol. Successful recanalization was defined as partial or complete recanalization of the portomesenteric venous thrombosis at the latest CT follow-up (n = 70).ResultsWe studied 102 patients (median age 58 years, 61 men). Lifelong anticoagulation was initiated in 64 patients, and bowel resection rate was 17%. No referral letter indicated suspicion of MVT, whereas three indicated suspected intestinal ischemia. Previous venous thromboembolism was associated with increased bowel resection rate (p = 0.049). No patient with acute pancreatitis (n = 17) underwent bowel resection (p = 0.068). The presence of mesenteric oedema (p = 0.014), small bowel wall oedema (p < 0.001), small bowel dilatation (p = 0.005), and ascites (p = 0.021) were associated with increased bowel resection rate. Small bowel wall oedema remained as an independent risk factor associated with bowel resection (OR 15.8 [95% CI 3.2–77.2]). Successful thrombus recanalization was achieved in 66% of patients.ConclusionThe presence of abnormal intestinal findings secondary to MVT confers an excess risk of need of bowel resection due to infarction. Responsible physicians should therefore scrutinize the CT images at diagnosis together with the radiologist to better tailor clinical surveillance.

Giant bezoar: young Rapunzel

Surgeons and radiologists encounter a challenge regarding the type of diagnostic imaging techniques to use when faced with a possible small bowel obstruction (SBO). However, with a sensitivity of 82%–100%...

Prolonged postoperative ileus in a patient with primary pneumatosis cystoides intestinalis: a case report

BackgroundPneumatosis cystoides intestinalis (PCI) is a rare disease characterized by multiple gas-filled cysts in the intestinal wall and is associated with various comorbidities. We report herein a case of intractable paralytic ileus caused by primary PCI.Case presentationA 73-year-old man visited out hospital complaining of abdominal pain and vomiting. He had been hospitalized twice for intestinal obstruction in the past 2 months. Based on his history of appendectomy, mechanical bowel obstruction caused by adhesion was diagnosed, and the patient underwent surgery. However, laparotomy revealed small bowel dilatation despite the absence of obstruction or stenosis. Multiple nodules were found in the wall of the dilated bowel loops. The dilated jejunum was excised. Histological examination revealed that the nodules were small gas-filled cysts, suggesting PCI. We made a diagnosis of ileus with underlying PCI and managed the patient conservatively. A large amount of nasogastric tube drainage continued for a long period postoperatively. The patient underwent relaparotomy 35 days after the first operation. The upper jejunum was markedly dilated, although no mechanical stenosis was found. The atonic, dilated jejunum was excised and the ileal stump was anastomosed to the duodenum in a double tract fashion. The patient underwent hyperbaric oxygen therapy because the ileus persisted postoperatively. His condition gradually improved and he was discharged 53 days after the second operation.ConclusionsNon-operative treatment is recommended for primary PCI of unknown etiology. Surgeons should be mindful of the possibility of primary PCI when considering surgical intervention for patients with bowel obstruction.

Congenital chloride diarrhea: A rare cause of recurrent polyhydramnios

Congenital chloride diarrhea (CCD) is a rare, inherited disorder. Our case was a preterm neonate who presented with severe watery diarrhoea since Day 2 of life. There was maternal history of polyhydramnios and dilated bowel loops. The diagnosis of CCD was confirmed by mutation analysis. The infant is 9 months corrected age, on salt and potassium supplementation, with age-appropriate milestones. The diagnosis of CCD must be made early to prevent life-threatening fluid and electrolyte imbalance.

Ультразвукова діагностика апендикулярних перитонітів у дітей

Мета роботи: вивчення можливостей ультразвукової сонографії (УЗС) при вказаній патології у дітей.Матеріали і методи. Для об’єктивної оцінки рухової активності кишки, ступеня поширеності патологічного процесу в черевній порожнині та задля динамічного контролю ефективності лікування обстежено 93 хворих віком від 2 до 15 років з апендикулярним перитонітом. Пацієнтів було розподілено на ІІ групи: I група порівняння – 45 хворих з апендикулярним перитонітом, ускладненим парезом кишечника I-II стадії. В II групу ввійшло 48 дітей с РГАП, ускладненим ПК (основна група). Оцінювали такі ехографічні показники: наявність рідини в черевній порожнині та її локалізацію; наявність перистальтики кишки; діаметр та товщина кишки; скупчення рідини та повітря у просвіті кишки; характер просування хімусу по кишці.Результати досліджень та їх обговорення. При порівнянні доопераційних показників УЗС з результатами інтраопераційної ревізії черевної порожнини виявлено, що в 91,2 % випадків ехографічні дані збігалися з інтраопераційними. На УЗС складно диференціювати паралітичну та механічну кишкову непрохідність. При цьому встановити діагноз простіше при ретельному обстеженні усіх відділів черевної порожнини, якщо вдається знайти ділянки петель кишки, які спалися, та розтягнуті петлі. На ранніх стадіях злукової кишкової непрохідності на УЗС вдається виявити ділянку кишки з перистальтичною хвилею. Маятникоподібний рух хімусу, ніби вдаряючись об перепону, відкочується назад.

Antenatal diagnosis of midgut volvulus with successful immediate post-natal management

Abstract Fetal volvulus of the midgut occurs when the bowel twists around the axis of the superior mesenteric artery. It is usually diagnosed postnatally but with improving ultrasonography, there have been increasing number of cases reporting antenatal diagnosis that had allowed planning of obstetric intervention and prompt surgery in the postnatal period. We present a case of dichorionic diamniotic twin pregnancy wherein Twin A had multiple anomalies, which included an Ivemark heterotaxy syndrome with a double outlet right ventricle. This twin developed dilated bowel loops at 33 weeks of gestation. The pregnancy continued to have regular antenatal surveillance and was managed by a multidisciplinary team. At 36 weeks of gestation, these bowel loops were found to have absence of peristalsis compared to previous ultrasounds. An emergency caesarean section was performed, which was uncomplicated and Twin A weighing 2760g was born with Apgars of 61 and 85. The diagnosis of volvulus in Twin A was confirmed during its emergency laparotomy along with a Type IV jejunal atresia and was successfully treated surgically with resection and administration of tissue plasminogen activator (TPA). This is the first description of a case treated with TPA after fetal diagnosis.

Computed tomography imaging of acute gastrointestinal graft-versus-host disease after haematopoietic stem cell transplantation in children.

Aim of the studyTo evaluate computed tomography (CT) findings of gastrointestinal graft-versus-host disease (GI-GVHD) occurring in children after haematopoietic stem-cell transplantation (HSCT).Material and methodsFrom February 2013 to May 2018, 225 paediatric patients underwent HSCT. Sixty-eight patients (30%) presented with clinical diagnosis of acute GI-GVHD in the first 100 days after HSCT. Thirty-five (18 girls, 17 boys; age range, 2–18 years; mean age, 10.3 years) of 68 patients had abdominopelvic CT and included in study.ResultsIntestinal CT abnormalities were present in 33 (94%) and extra-intestinal CT findings were in 30 (86%) patients. Thickening of the bowel wall was the most common finding (31 patients, 89%), which involved the small bowel in 29 patients (83%), colon in 16 patients (46%), and both in 15 patients (43%). Oesophageal wall thickening was present in three patients (9%), and gastric wall thickening was in eight patients (23%). Bowel dilatation was detected in 13 patients (37%). Mucosal enhancement of the bowel wall was observed in 28 patients (80%). The prevalence of the extra-intestinal CT findings were: periportal oedema in nine (26%), ascites in 15 (43%), wall thickening and enhancement of gall bladder in 13 (37%), pericholecystic fluid in six (17%), hepatomegaly in 13 (37%), and splenomegaly in nine (26%) patients. One patient (3%) demonstrated free intraperitoneal air due to intestinal perforation.ConclusionsCT is useful to support the clinical diagnosis of acute GVHD in children with GI symptoms after HSCT. Radiological evaluation is important because early diagnosis and treatment affect the prognosis of GI-GVHD.

Left transverse loop colostomy versus high sigmoid loop colostomy for high-type anorectal malformations: Early outcome analysis

Background: High sigmoid (divided) colostomy has been recommended by various studies for the management of high-type anorectal malformation (ARM). It is postulated to be associated with fewer complications. Aims: To compare the complications related to left transverse loop colostomy and high sigmoid loop colostomy done in male patients with high-type ARM and share our experience. Materials and Methods: A prospective study on all male neonates admitted with high-type ARM at our high-volume tertiary care institute from January 2014 to March 2016 was carried out. The patients were randomized and divided into two groups (group A: left transverse loop colostomy and group B: high sigmoid loop colostomy). The patient's clinical presentation, operative course, and complications were recorded. Results: Of 158 male neonates who were subjected to loop colostomy, 93 (58.9%) were in group A and 65 (41.1%) in group B. Mortality was higher in group B (16.9%) than group A (8.6%), but none directly related to the type of colostomy. Intraoperative complications (technical difficulties) such as difficulty in approaching the sigmoid colon with dilated small bowel loops and identifying the proximal and distal parts of sigmoid colon along with handling of the bowel (including serosal tears) were significantly more in group B (20%) than group A (1.07%) where transverse colon was easily exteriorized. The average time taken for the procedure, pericolostomy excoriation, and bowel obstruction was more in group B when compared with group A. Conclusion: Left transverse loop colostomy works well to relieve the obstruction and is less time-consuming, particularly with late presentation. We recommend left transverse loop colostomy in cases of high-type male ARM because of the ease of procedure and comparatively low complication rates.

Point of Care Ultrasound Illustrating Small Bowel Obstruction

History of present illness: A 38-year-old female presented to the emergency department (ED) with abdominal pain, vomiting and constipation for one day. She had a history of hysterectomy and oophorectomy secondary to severe endometriosis three years prior to her visit. She also reported a history of small bowel obstruction (SBO) which was managed conservatively. Her vitals were unremarkable except for mild tachycardia. Point of Care Ultrasound (POCUS) was performed which showed severely dilated loops of bowel with concern for SBO. A CT scan was performed to confirm the diagnosis and identify the cause and the level of the obstruction. The patient’s CT scan confirmed the SBO and found a transition point near the terminal ilium. Significant findings: POCUS of the small bowel illustrated significantly dilated loops of bowel (white line), thickened bowel wall (white arrow) and to-and-fro peristalsis, consistent with small bowel obstruction. Discussion: Approximately two percent of patients who present to the ED with abdominal pain are diagnosed with SBO.1-2 POCUS has been shown to have a sensitivity of 92.4% and specificity of 96.6% for the diagnosis of SBO.3 The proper way to scan patients with suspected SBO is by using the curvilinear probe (3-5 MHz) across the entire abdomen. Pathologic findings include bowel dilatation (which can be measured from the inner wall to the inner wall of the small bowel) greater than 2.5cm. Other positive findings include to-and- fro peristalsis, mesenteric thickening and thickening of valvulae conniventes. Wall thickening greater than 3 mm and free fluid between bowel loops may suggest bowel ischemia.4 Despite the high diagnostic accuracy of the POCUS, it can be operator dependent and is limited by the ability to accurately identify a transition point. CT scan also has the advantage of determining the underlying cause and identifying the exact location of the obstruction.5 Given the findings and diagnosis, this patient was admitted to the surgical ward and managed conservatively. She improved the next day and diet was advanced. She was discharged home on hospital day 3 after resolution of her symptoms. Topics: Point of care ultrasound, small bowel obstruction.

A case with hydroureteronephrosis accompanied by Lupus Mesenteric Vasculitis

Lupus mesenteric vasculitis is an uncommon and severe complication of systemic lupus erythematosus (SLE). Frequently, these patients exhibit dilated bowel segments, focal or diffuse thickening of the intestinal walls, abnormal contrast enhancement in the intestinal wall, target or double halo, mesenteric edema, engorged mesenteric vessel and ascites in abdominal computerized tomography (CT) imaging. However, these signs lack specificity, limiting the diagnostic role of CT. Intestinal pseudo-obstruction in association with hydroureteronephrosis has been previously reported in SLE patients. Here in, we report a case of lupus mesenteric vasculitis occurring in conjunction with hydroureteronephrosis. Presence of hydroureteronephrosis may assist in improving the specificity of CT in lupus mesenteric vasculitis.

Bowel ultrasound for predicting surgical management of necrotizing enterocolitis: a systematic review and meta-analysis

BackgroundNecrotizing enterocolitis (NEC) is a devastating inflammatory disease of the intestinal tract that represents a significant source of morbidity and mortality in preterm infants. Imaging of the abdomen is valuable for timely diagnosis and close monitoring of disease progression in NEC. Bowel ultrasound (US) is increasingly being recognized as an important imaging tool for evaluating NEC that provides additional detail than plain abdominal radiographs.ObjectiveTo identify bowel US findings associated with surgical management or death in infants with NEC.Materials and methodsWe searched Embase, PubMed, and the Cumulative Index to Nursing and Allied Health Literature for studies investigating the association between bowel US findings and surgical management or death in NEC. Selected articles were evaluated for quality of study methodology using the Newcastle-Ottawa Scale, and aggregate statistics for odds ratio (OR) and 95% confidence interval were calculated.ResultsOf 521 articles reviewed, 11 articles comprising 748 infants were evaluated for quality. Nine of the studies were retrospective and from single-center experiences. Pooled analysis showed that focal fluid collections (OR 17.9, 3.1–103.3), complex ascites (OR 11.3, 4.2–30.0), absent peristalsis (OR 10.7, 1.7–69.0), pneumoperitoneum (OR 9.6, 1.7–56.3), bowel wall echogenicity (OR 8.6, 3.4–21.5), bowel wall thinning (OR 7.11.6–32.3), absent perfusion (OR 7.0, 2.1–23.8), bowel wall thickening (OR 3.9, 2.4–6.1) and dilated bowel (OR 3.5, 1.8–6.8) were associated with surgery or death in NEC. In contrast, portal venous gas (OR 3.0, 0.8–10.6), pneumatosis intestinalis (OR 2.1, 0.9–5.1), increased bowel perfusion (OR 2.6, 0.6–11.1) and simple ascites (OR 0.54, 0.1–2.5) were not associated with surgery or death.ConclusionThis meta-analysis identified several bowel US findings that are associated and not associated with surgery or death in NEC. Bowel US may be useful for early identification of high-risk infants with NEC who may benefit from more aggressive treatment, including surgery. Future studies are needed to determine whether the addition of bowel US in NEC evaluation would improve outcomes.

A Rare Cause of Progressive Constipation, Abdominal Distension, and Weight Loss

A 46-year-old man was referred for evaluation of a 1-year history of progressive constipation, bloating, and 40-lb weight loss. These symptoms had previously been attributed to Crohn’s colitis, but improvement was not achieved after several months of adalimumab. Computed tomography enterography demonstrated prominent distal small bowel dilation with several short segment strictures, bowel wall thickening, and mucosal hyperenhancement (Figure A, arrow). Laparotomy was pursued for surgical management of the strictures. Intraoperatively, the small bowel was massively dilated up to 15 cm, notably uncharacteristic for Crohn’s-associated strictures (Figure B), and full-thickness small bowel biopsies were obtained. Histologic review with smooth muscle actin (Figure C, arrows) and smoothelin staining (Figure D, arrows) demonstrated myocyte degeneration from the inner and outer layers of the muscularis propria, without features of neural degeneration or Crohn’s disease. Based on these clinical and histologic features, a diagnosis of degenerative leiomyopathy complicated by intestinal pseudo-obstruction was established. Postoperatively, adalimumab therapy was discontinued and the patient was initiated on prucalopride and a regulated bowel regimen with complete symptomatic resolution. This case highlights the importance of pursuing additional testing in the setting of discordant findings.

A phlegmon secondary to retroileal appendicitis: A rare cause of mechanical small bowel obstruction

Introduction Appendicitis is common surgical emergency with a lifetime risk of about 7% and a perforation risk of 17-20%. In young patients diagnosis does not pose a great difficulty and the surgical management is generally good. However in the elderly with varied presentation and a difficult history, the diagnosis can be more challenging. Small bowel obstruction as a result of adhesions from appendicitis has been commonly documented in literature. But mechanical small bowel obstruction caused directly as a result of acute appendicitis is rare. We present one of this rare and interesting presentation of appendicitis. Case description An 83-year-old gentleman presented to the surgical department with a 4-day vague history of abdominal pain associated with vomiting. He had not opened his bowels for a similar time period and also complained of abdominal distension. The patient had an unremarkable past surgical history, with no prior abdominal surgery. General examination showed he was dehydrated, exhausted and looked unwell. His pulse was 94/min, BP was 120/60mmHg and he was apyrexial. His abdomen was markedly distended but soft and non-tender with sluggish bowel sounds. Abdominal x-Rays showed multiple loops of dilated small bowel suggestive of small bowel obstruction. Initially the patient was managed by intravenous fluid resuscitation, nasogastric tube insertion and urethral catheterisation. An arterial blood gas analysis showed significant metabolic acidosis with raised serum lactate and negative base excess. Routine bloods showed raised urea, creatinine and WCC. Despite rigorous resuscitation the patient’s condition deteriorated, hence an emergency laparotomy was performed. At surgery loops of distended small bowel were identified extending proximally from the duodeno-jejunal junction to the distal ileum. At approximately 8cm from the ileo-caecal valve, a small appendix was noticed behind the transition point covered in a phlegmon and surrounding inflammation. A routine appendicectomy was performed and the abdomen was closed after thorough wash out with normal saline. No other abnormality was noticed on laparotomy. Unfortunately the patients died a few days after the operation from pneumonia. Results and Conclusions Appendicitis is the second most common surgical abdominal pathology in people over 50yrs of age. The diagnosis in this age group is often delayed compared to the younger group due to a variety of reasons including difficult history and atypical and delayed presentation. In our case the cause of mechanical small bowel obstruction was noted to be due to inflamed small appendix and phlegmon lying behind the terminal ileum. Presumably the patient must have developed appendicitis a few days prior to presentation to the hospital. This delay had caused the development of phlegmon in which the appendix was found wrapped causing intestinal obstruction. Mechanical small bowel obstruction is recognized as short-term complication (ileus) and long-term adverse effect due to postoperative adhesion after appendicectomy. In literature, appendicitis as a direct cause of small bowel obstruction has been discussed but without describing the position of the appendix and most cases were secondary to perforated appendices and associated peritonitis. Small bowel obstruction without previous surgery to the abdomen is acute surgical emergency and early judicious intervention is needed to improve the final outcome. This case is unique in its presentation of appendicitis and without any obvious signs making the pre-operative diagnosis difficult.

A rare cause of small bowel obstruction which should always be considered

Introduction Appendicitis has been known to cause acute small bowel obstruction through mechanical and physiological interactions with the ileum. Here a 52 year old male, who, following 3 days of lower abdominal pain, bowels not having opened and vomiting was found on computed tomography (CT) scan to have a mechanical small bowel obstruction. This was operated on via lower midline laparotomy and adhesiolysis. An inflamed appendix was found to have wrapped itself around the terminal ileum causing a focal stricture. After appendectomy the patient was discharged 6 days later and made a full recovery. Case description A 52 year old man with a past history of GORD, hypertension and peripheral vascular disease (with aorto-bifemoral bypass) was admitted onto our Surgical Triage Unit (STU) at 22:10 on a Thursday evening. He complained of a 3 day history of illness consisting of cramping lower abdominal pain, bowels not having opened and recurrent bilious vomiting. Results and Conclusions An urgent CT scan reported “High grade small bowel obstruction, with change of calibre in the distal ileum. This may be secondary to adhesions (previous bilateral femoral bypass) or internal hernia. Incidentally, the appendix also looks inflamed. No perforation or intra-abdominal collections.” At laparotomy, the appendix was inflamed with free pus in the peritoneal cavity and dilated small bowel loops in the vicinity. On closer inspection it could be seen that the inflamed appendix had wrapped itself around the terminal ileum stenosing its lumen and causing the small bowel obstruction. Take home message • Always consider a concurrent appendicitis in cases of small bowel obstruction • Do not exclude an appendicitis in cases of left sided abdominal pain as was the case here • If suspected consider performing computed tomography before proceeding to surgery • The co-existence of these two pathologies may alter operative approach

Deadly combination: Clostridium septicum and colorectal malignancy

Gas gangrene is a life-threatening, necrotising soft tissue infection. Colorectal malignancy-associated Clostridiumsepticum is a rare cause of gas gangrene. This case outlines an initial presentation of colonic malignancy as gas...