Obstructive uropathy in the context of ureteroinguinal hernia: experience of challenges in surgical management of an unwell patient.

This case exemplifies an unusual anatomical variation of a common presentation and highlights the importance of perioperative diagnosis and planning in complex surgical patients. A 72-year-old comorbid man presented to the emergency department with an infected obstructed right kidney secondary to an obstructing 12 mm vesicoureteric junction calculi. However, imaging also showed concurrent ureteroinguinal hernia associated with a 130 cm-long ureter, too long for conventional treatment with a ureteric stent. Acutely, the patient's collecting system was decompressed via nephrostomy, but due to the rarity of this anatomical variation, definitive treatment had to be rethought to help reduce the risk of iatrogenic damage and the associated long-term complications.

Burns in children: the importance of assessing for non-accidental injuries.

Children represent 30% of all burn cases seen by accident and emergency physicians in the UK every year, with toddlers being most at risk within this age group. With the emergence of walking autonomy, the need for constant supervision is sometimes not enough to prevent this type of injury from happening. However, in remembering the importance of children's health and safety, non-accidental injury is always to remain a differential diagnosis. The authors review a paediatric burns case underlying the importance of keeping an open mind to allow a proper clinical diagnosis to be formed.

Choledochal-duodenal fistula presenting as an upper GI bleed.

Gallstones are common and largely asymptomatic, but can result in significant morbidity in a small proportion of patients. Choledochal-enteric fistulation is one such complication with an associated mortality of 15-18%. The authors present a case of an 88-year-old man admitted to the general medical ward with an acute upper gastrointestinal bleed. Oesophagogastroduodenoscopy found a large gallstone impacted in the pylorus and CT scan revealed a choledochal-duodenal fistula. At laparotomy it was found that a 6.2 cm gallstone had fistulated into D1 and the pylorus and impacted there, causing outflow obstruction - Bouveret's syndrome. A subtotal cholecystectomy was performed and the stone was removed by a separate gastrostomy. A radiological follow through study on day 14 showed contrast passing freely through the duodenum with no leak and the patient went on to make a slow, but uneventful recovery.