Non-steroidal anti-inflammatory drug induced intestinal stricturing: diaphragm disease.

Diaphragm disease (DD) is a rare small bowel enteropathy associated with non-steroidal anti-inflammatory drug use. Since the first description there have only been approximately 100 cases of DD reported in the literature. Stricturing webs or 'diaphragms' form in the bowel, causing non-specific abdominal symptoms that can ultimately lead to bleeding and obstruction. Diagnosis is notoriously challenging as there is no single gold standard investigation. We present two cases of DD both of which were ultimately diagnosed by surgical resection. We also propose a novel flow algorithm that can be utilized for working up patients with suspected DD.

Falciform ligament torsion as a rare aetiology of the acute abdomen.

The falciform ligament is a remnant of the embryonic ventral mesentery containing the obliterated umbilical vein and round ligament. It extends from the umbilicus to the superior aspect of the diaphragm. We report about a 53-year-old fit and well patient who presented with acute upper abdominal pain with tenderness to palpation. Ultrasound scan was unremarkable, but blood tests revealed raised inflammatory markers. Thus, computed tomography was performed. This demonstrated acute torsion and fat necrosis of the falciform ligament, which was the aetiology of the upper abdominal pain. Such pathology is rare with 23 previously reported cases. Conservative management is usually proposed, but on occasion, surgical intervention may be warranted in cases that do not respond to initial supportive measures. We describe this case to demonstrate a rare cause of a common presentation to the surgical service.