A case of haemorrhagic cholecystitis with no risk factors.

Haemorrhagic cholecystitis (HC) is a rare cause of cholecystitis that can be fatal if management is delayed. HC could present in the setting of trauma, malignancy and bleeding diathesis, such as renal failure, cirrhosis and anticoagulation. Its symptoms are easily confused with acute calculous or acalculous cholecystitis and might include haemobilia or hematemesis as blood drains from the gallbladder into the gastrointestinal tract. Imaging of HC can be misleading unless the possibility of this diagnosis is considered. In this report, we present an interesting case of HC in a patient with none of the above comorbidities and the patient who was not on anticoagulation neither anti platelets. The case includes relevant imaging and a review of the literature on this rare subject.

Synchronous Acute Appendicitis and Cholecystitis in a Paediatric Patient with Salmonella Enteritis.

We present the case of a 13-year-old male who presented with right upper quadrant pain and diarrhoea after recently travelling from Bali, Indonesia. He had a normal white cell count of 8x10^9/L and elevated c-reactive protein (CRP) of 205 mg/L with normal liver function tests. Originally thought to be appendicitis, given the rarity of cholecystitis in a child, he was commenced on broad-spectrum antibiotics and was taken to the operating theatre based on his clinical presentation. Diagnostic laparoscopy revealed inflammatory change in both the gallbladder and appendix and a laparoscopic cholecystectomy and appendicectomy were performed simultaneously. Histopathology results confirmed cholecystitis and appendicitis and a stool culture confirmed the presence of Salmonella serotype B. Synchronous cholecystitis and appendicitis is an exceedingly rare phenomenon with only a handful of cases reported in the literature. This is the first case in the literature of this phenomenon occurring in the paediatric population; surgeons need to be aware of this rare possibility even in the paediatric population and especially in those patients with an atypical presentation or in recent travellers experiencing gastroenteritis.

Small Bowel Perforation Secondary to Biliary Stent Migration in an Incarcerated Inguinal Hernia.

We describe the case of a 90-year-old female who presented with signs of a strangulated inguinal hernia. Further history revealed a paired biliary-pancreatic stent insertion three years prior for ascending cholangitis and a long-standing asymptomatic right inguinal hernia. Biochemistry revealed a slightly elevated C-reactive protein level of 65 mmol/L, but was otherwise unremarkable. Abdominal CT demonstrated two plastic biliary stents within an incarcerated right inguinal hernia. At the time of surgery, a 3-mm perforation due to the stents was identified in the small bowel within the hernia. The stents were retrieved via an enterotomy that was subsequently repaired with full-thickness interrupted sutures. A tissue-suture repair of the inguinal hernia was performed due to significant contamination of enteric contents in the operative field. The patient had an unremarkable recovery and was discharged four days after her operation. This is a very rare acute presentation of stent migration with only a handful of such reported cases in the literature. With the rising number of endoscopic biliary stenting procedures, these complications are likely to increase, and clinicians need to be aware of this possibility in patients with pre-existing hernias.

Primary Small Bowel Volvulus: An Unusual Cause of Small Bowel Obstruction.

We present the case of a 78-year-old female who presented to the emergency department with small bowel obstruction in a virgin abdomen. Although the patient did not have peritonism and biochemical investigations did not reveal alarming features of ischemia, an abdominal computed tomography (CT) scan was suggestive of small bowel volvulus (SBV), and operative exploration was pursued. No obvious cause was identified aside from hard stools throughout the colon and a diagnosis of primary SBV was determined. She was subsequently discharged symptom-free on day seven post-operatively. She re-presented on day 10 post-operatively with a similar history, examination, and abdominal CT findings suggestive of SBV recurrence. Her volvulus slowly resolved post administration of rectal enemas and did not require any further operative intervention; she was discharged on day eight of re-admission (day 19 post-operatively) with no recurrence of her symptoms on a regular diet. In this article, we discuss the management of SBV.