Liver perforation following foreign body ingestion: an important clinical lesson.

A 25-year-old woman presented to the surgical unit with a 1-week history of ingestion of a pen. Examination revealed a minimally tender epigastrium with no peritonism. Investigations were unremarkable, with normal bloods and no free air on erect chest radiograph. At the time of endoscopy, the pen appeared to have perforated the lesser curve of the stomach. Endoscopic extraction was abandoned and a CT arranged, revealing the tip of the pen lying within the left lobe of the liver. The pen was removed at laparotomy with an uneventful recovery. This case highlights the importance of considering the potential for injury to other structures following gastric perforation, and the importance of having a low threshold for further imaging.

Improving the education and experience of foundation doctors in general surgery.

Reduced working hours and fragmentation of the surgical firm has resulted in a gradual change in FY1 duties. Locally, FY1 doctors were no longer routinely seeing surgical emergency admissions, while FY1s informally reported reduced confidence in dealing with surgical emergencies. The goal of this project was to assess the current training of FY1 doctors within the unit, and to attempt to improve this by increasing exposure to surgical emergencies. Two months into their four month surgical rotation, FY1s completed an anonymous online survey that focused on their confidence in dealing with emergency surgical admissions. Working practice was then changed by the creation of a formal emergency foundation year one (FY1) rota, and the introduction of a baton bleep. The expectation was that all emergency admissions would be clerked by an FY1 doctor. The cohort were asked to repeat the survey after implementation of change. Across all areas assessed, the confidence and experience of the junior doctors was improved. Initially 70% of FY1s felt exposure to emergency surgical cases was inadequate, falling to 0% after the intervention. This was associated with a rise in the average number of acute cases clerked by each FY1 per week from 1.2 to 4.0. At baseline, only 30% of those surveyed felt that they were gaining the skills and experience necessary to prepare them for an FY2 job in general surgery, and after the intervention this increased to 100%. The increased pressures of service provision within reduced working hours does not necessitate the exclusion FY1 doctors from the assessment and management of surgical emergencies. We have demonstrated that preserving this exposure is a priority in the training of junior doctors, resulting in more experienced and confident medical staff.

Radiological diagnosis of a small bowel perforation secondary to toothpick ingestion.

A 77-year-old edentulous man presented to the accident and emergency department with a sudden onset of sharp right-sided abdominal pain. The patient reported a change in his bowel habit with constipation over a 6 month period but did not report any significant choking event or ingestion of a foreign body in the preceding months. On examination the patient was maximally tender with guarding over McBurneys point. CT scan showed an abnormal segment of distal ileum with a 3 cm high attenuation focus which had penetrated the bowel wall. At laparotomy the patient was found to have a perforation of his distal ileum caused by an ingested toothpick. Patients wearing dental plates or dentures are at higher risk of toothpick ingestion due to impaired palatal sensation. CT scanning, in the appropriate setting, may aid diagnosis and lower operator risk of sharp related injury at the time of operation.