An unexpected CT finding in a patient with abdominal pain.

A fit and well 16-year-old girl presented to the emergency department with signs and symptoms suggestive of appendicitis. A transabdominal ultrasound scan revealed a normal appendix but there was significant free fluid in the pelvis. Consequently, a CT scan of her abdomen was performed which showed mucosal oedema and inflammation involving virtually the entire length of her large bowel (the 'accordion sign'). Clostridium difficile colitis was thus suspected; however, the toxin was not detected in her stool. The patient was treated conservatively with intravenous fluids and antibiotics and had an uneventful recovery. She was subsequently discharged home 3 days later with a full recovery. In this case, the radiological appearance of the accordion sign which is traditionally known to be pathognomonic of pseudomembranous colitis, reveals that it may also be indicative of severe colonic luminal inflammation.

An unusual presentation of cholecystoduodenal fistula: vomiting of gallstones.

Bouveret's syndrome is defined as gastric outlet obstruction secondary to an impacted gallstone in the duodenum via a cholecystoduodenal or cholecystogastric fistula. Common radiological findings include pneumobilia, calcified right upper quadrant mass, pyloric or duodenal obstruction and cholecystoduodenal fistula. Initial attempts through endoscopic retrieval may be successful; however, results can vary. Surgical options include enterolithotomy or gastrotomy with or without cholecystectomy and fistula repair. We describe a unique case of Bouveret's syndrome with short-lived obstruction followed by vomiting of gallstones in a morbidly obese patient and discuss the complexities of investigation and management of these patients.

A literature review of spontaneous evisceration in paediatric umbilical hernias.

Umbilical hernias occur frequently in children but complications are very rare and thus surgery is not routinely indicated. In this literature review, we report 19 cases of spontaneous evisceration of abdominal contents through umbilical hernias. Precipitating causes included umbilical ulceration or sepsis, crying, respiratory infection, intussusception and ascites. Management involved resuscitation and surgical repair. Mortality is low. As the incidence of spontaneous rupture is very low, the current management of an umbilical hernia remains appropriate. However, we encourage physicians to be aware of the potential risk factors for spontaneous rupture and in these patients expedite surgical repair.