Spontaneous rupture of splenic artery pseudoaneurysm.

False aneurysm or visceral artery pseudoaneurysm (VAPA) results from a tear in the vessel wall due to trauma with subsequent periarterial haematoma formation. VAPA is relatively rare, with a reported incidence of 0.1-0.2%, although the actual incidence is not known since many are asymptomatic. Splenic artery pseudoaneurysm is even more rare pathology. Only around 200 cases have been described in the literature. The case report below describes a spontaneous rupture of splenic artery pseudoaneurysm.

Sparganosis: an under-recognised zoonosis in Australia?

Sparganosis is a rare zoonotic parasitosis that is sporadically reported worldwide. In Australia, the causative tapeworms are considered endemic in wildlife animals, however, there have been only five reported human infections. We present three additional cases of sparganosis, involving two Australian born gentlemen who have never travelled overseas and a woman who emigrated from Ethiopia. The first man presented with two unusual subcutaneous lumps that migrated along the anterior abdominal wall connected by a tunnel. The second man presented with two separate lumps, one on the thigh and the other on the left upper abdomen over a 4-week interval. The woman presented with 6 weeks of intermittent fevers, night sweats, abdominal pain and passing intestinal worms. This series of patients suggests that sparganosis is under-recognised in Australia and serves as a reminder for clinicians to the varied presentations that can be characteristic of this lesser known zoonosis.

Rates of colorectal cancer detection in screening colonoscopy post appendicectomy in patients 50 years and over.

INTRODUCTION: Acute appendicitis in older adults is relatively uncommon and could be the first presentation of an underlying colorectal carcinoma. Colonoscopy in these individuals affords the opportunity for earlier diagnosis and treatment. The finding of increased rates of colorectal cancer (CRC) with older patients who have had appendicitis was supported by a number of small studies and case reports in the early 1980s.With the advent of CT scanning and laparoscopic appendicectomy, increased ability to visualize the caecum has been achieved. PURPOSE: A retrospective 12-month study of all patients presenting with acute appendicitis aged 50 years and over from 1st May 2017 to 31st May 2018, and review of post operative screening colonoscopy findings. RESULTS: Forty-three patients met inclusion criteria. The patients' median age was 62 years (range 50-85 years). 47% of the patients were male. 86% of patients had abdominal CT scans prior to surgery with acute appendicitis visualized in 97% of these cases. Acute appendicitis was found in 100% of cases with no clinical suggestion of CRC operatively or pathologically. 46% of patients had pertinent findings on colonoscopy. This included a malignant obstructing tumour at the hepatic flexure and a tubular adenoma in the transverse colon in a second patient. The remaining findings in this cohort of patients included diverticular disease and benign polyps. CONCLUSION: Despite the advancement in visualization of anatomy with CT scan and laparoscopic appendicectomy there is still a role for screening colonoscopy in patients greater than 50 years of age with appendicitis particularly if they have associated bowel symptoms or risk factors for CRC.

Pneumatosis intestinalis a trap for the unwary: Case series and literature review.

INTRODUCTION: Pneumatosis Intestinalis (PI) can present with a broad range of presentations from chronic and non-specific to acute and life threatening. It is paradoxically one of the few conditions where a pneumoperitoneum found in the diagnostic workup is not necessarily an indication for laparotomy. PRESENTATION OF CASES: The first case is of a 75 year old gentlemen who attended the emergency department after several weeks of worsening abdominal pain and weight loss. At laparotomy, two segments of nodular, abnormal-looking small bowel were identified with bubbles of air seen in the small bowel mesentery. The second case is of an 86 year old man with of a 5-month history of abdominal pain, weight loss, nausea and diarrhoea. A subsequent endoscopy revealed diffuse gastritis with a small antral gastric ulcer with a small amount of blood. The CT scan demonstrated free air within the bowel wall, with a follow up scan performed 3 weeks later revealing an increase in the amount of free air. DISCUSSION: PI is a rare condition characterised by the presence of subserosal and submucosal gas filled cysts occurring anywhere in the gastrointestinal tract from the oesophagus to the anus. Numerous conditions have been associated with PI including bowel obstruction, infections, ischemia and there have been reported cases suggesting as association with Crohn's disease. CONCLUSION: PI is a condition that may manifest with a wide range of symptoms from mild abdominal pain to acute peritonitis. Its treatment is generally medical and even with radiological evidence of perforation laparotomy may not be indicated if the patient is clinically well.

Cholecystitis secondary to gallbladder torsion - A rare case report.

INTRODUCTION: Gallbladder torsion is a rare condition of increasing prevalence in recent years. It is often difficult to diagnose pre-operatively and delayed intervention can lead to significant complications. PRESENTATION OF CASE: We present a case of an 81 year old lady who presented with symptoms of cholecystitis for 24 h with no evidence of cholelithiasis on imaging. She deteriorated within 24 h of admission despite intravenous antibiotics; Emergency laparoscopy was performed which showed the gallbladder malrotated 180 ° with features of necrosis. Laparoscopic cholecystectomy was performed without complications. DISCUSSION: The cause of gallbladder torsion are thought to be due to underlying anatomical variations or loss of elasticity associated with aging. Diagnosis is difficult clinically and radiologically, however, features such as "whirl sign" and "cystic duct knot sign" have been described. Due to ischemia associated with torsion, clinical vigilance and early intervention is recommended to prevent potential fatal sequelae particularly in the elderly population. CONCLUSION: Gallbladder torsion is a rare finding that can be difficult to diagnose clinically, we are hoping to promote awareness to prevent complications associated with delayed therapy.

Management of extensive surgical emphysema with subcutaneous drain: A case report.

INTRODUCTION: Subcutaneous emphysema (SE) is a frequent and often self-limiting complication of tube thoracostomy or other cardiothoracic procedures. On rare occasions, severe and extensive surgical emphysema marked by palpable cutaneous tension, dysphagia, dysphonia, palpebral closure or associated with pneumoperitoneum, airway compromise, "tension phenomenon" and respiratory failure require treatment. PRESENTATION OF CASE: A 67 year old lady presented with a large spontaneous pneumothorax on the background of end-stage chronic obstructive pulmonary disease (COPD) and newly diagnosed lung cancer, developed extensive surgical emphysema following insertion of a chest drain. Immediate improvement was observed after insertion of a large-bore, 26 French (Fr.) intercostal catheter, subcutaneous drain which was maintained under low suction (-5 cm H2O) for a further 24 h. DISCUSSION: Several methods have been described in the literature for the treatment of extensive subcutaneous emphysema, including: emergency tracheostomy, multisite subcutaneous drainage, infraclavicular "blow holes" incisions and subcutaneous drains or simply increasing suction on an in situ chest drain. Here a large-bore, fenestrated, subcutaneous drain maintained on low negative pressure also provided the necessary decompression. CONCLUSION: In the absence of a comparative study to identify the most effective method to manage extensive subcutaneous emphysema, this case highlights an effective, simple and safe management option.

Eosinophilic cholecystitis with common bile duct stricture: a rare disease.

Although the most common cause of cholecystitis is gallstones, other conditions may present as acute cholecystitis. We describe a case of eosinophilic cholecystitis with common bile duct stricture. A 36-year-old woman initially had generalised abdominal pain and peripheral eosinophilia. Diagnostic laparoscopy showed eosinophilic ascites and necrotic nodules on the posterior abdominal wall. She was treated with anthelminthics on presumption of toxacara infection based on borderline positivity of serological tests. She later presented with acute cholecystitis and had a cholecystectomy and choledocotomy. Day 9 T-tube cholangiogram showed irregular narrowing of the distal common bile duct. The patient's symptoms were improved with steroids and the T-tube was subsequently removed.

White-eyed blowout fracture: another look.

Orbital floor fractures have the potential to cause significant morbidity both in the short and long terms and commonly present to the ED for initial assessment. Although treatment of the majority of these injuries involves clinic review and possible later surgery, there is a specific subset that present to emergency clinically suggestive of a head injury. This subset, 'white-eyed blowout', usually occurring under 18 years of age, with a history of trauma and little sign of soft tissue injury, describes a trap door orbital floor fracture with herniation and acute entrapment of orbital muscle and is regarded as a maxillofacial emergency. The injury presents with marked nausea, vomiting, headache and irritability suggestive of a head injury that commonly distracts from the true aetiology. It requires prompt diagnosis and treatment to avoid permanent morbidity. We present three cases and discuss their management.

Anastomotic leakage is predictive of diminished survival after potentially curative resection for colorectal cancer.

OBJECTIVE: The aim of this study was to determine whether anastomotic leakage has an independent association with overall survival and cancer-specific survival. SUMMARY BACKGROUND DATA: There are many known prognostic indicators following surgery for colorectal cancer (CRC). However, the impact of anastomotic leakage has not been adequately assessed. METHODS: Consecutive patients undergoing resection between 1971 and 1999 were recorded prospectively in the Concord Hospital CRC database. Total anastomotic leakage was defined as any leak, whether local, general, or radiologically diagnosed. Patients were followed until death or to December 31, 2002. The association between anastomotic leakage and both overall survival and cancer-specific survival was examined by proportional hazards regression with adjustment for other patient and tumor characteristics influencing survival. Confidence intervals (CI) were set at the 95% level. RESULTS: From an initial 2980 patients, 1722 remained after exclusions. The total leak rate was 5.1% (CI 4.1-6.2%). In patients with a leak, the 5-year overall survival rate was 44.3% (CI 33.5-54.6%) compared to 64.0% (CI 61.5-66.3%) in those without leak. In proportional hazards regression-after adjustment for age, gender, urgent resection, site, size, stage, grade, venous invasion, apical node metastasis and serosal surface involvement-anastomotic leakage had an independent negative association with overall survival (hazard ratio [HR] 1.6, CI 1.2-2.0) and cancer-specific survival (HR 1.8, CI 1.2-2.6). CONCLUSION: Apart from its immediate clinical consequences, anastomotic leakage also has an independent negative association with survival.