Emphysematous gastritis and gastric emphysema remain the two most important differential diagnoses of intramural gastric air bubbles, both differing vastly in their clinical presentation, radiographic findings, management and prognosis. This report discusses a case of gastric emphysema along with the importance of reaching an accurate clinical diagnosis early in the disease course.

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It is important to know the contraindication and end point of Gastrografin trial in adhesive small bowel obstruction.Keywords Bowel . Obstruction . Abdomen . Surgery . Gastrografin Dear EditorWe read the article titled "Prospective Evaluation of Oral Gastrografin® in the Management of Postoperative Adhesive Small Bowel Obstruction" with profound interest as we regularly use in our centre the oral Gastrografin in the management of adhesive small bowel obstruction as per the merit of each case. As this article is available freely in PubMed, it gives us the opportunity to access and read it easily. Here, I take the liberty to highlight a few points that we think might be relevant in the context of this article. In addition to the exclusions mentioned in the article, it is important to identify few other groups of patients who may not befit a trial of therapeutic Gastrografin. It is very important to carry out an appropriate investigation to rule out closed bowel loop obstruction, as delayed diagnosis will only exacerbate the problem.Any patient showing an evidence of peritonism or hollow viscus perforation should proceed for immediate surgery. Lastly, overwhelming sepsis, persistent metabolic acidosis (despite rehydration), high and persistent base deficit and impending or established organ failure should also be excluded from this trial.I would like to make the following comment with regard to the end point of the trial. Our current practise is to wait for 4 h for the Gastrografin to reach the caecum; failing which, surgical exploration is more likely sooner rather than later [1,2]. Although conservative management can be carried out for days together, the failure of the contrast to reach the large bowel within 24-36 h mandates an assessment of a clinical condition to determine the need for a possible surgical intervention.

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Background: Two methods have been used for peritoneal access to create pnemoperitoneum-the open and the closed technique. We are describing here an open technique of creating pneumoperitoneum through the umbilical cicatrix. We have been using this technique routinely in view of its safety, rapidity and technical ease. Materials and methods: This method was used in 156 patients serially to create pneumoperitoneum. Patients were followed at 10 days, 3 months and 1 year interval. Results: The time range was 22 to 540 seconds. The mean time taken was 85 seconds. More than 70% of the patients (n = 110) fell in the range of 22 to 80 seconds where as 36 were in the range of 80 to 100 seconds. Ten patients had the range of 100 to 540 seconds. There were no incidences of vessel or viscus injury even in reoperative cases. There were no cases of any major bleeding or hematoma. Two cases had wound infection which subsided with antibiotic and wound drainage. Out of 42 patients who have completed 3 months follow-up and 11 patients who have completed 1 year followup, none showed any port site hernia. Conclusion: The open technique of creating pneumoperitoneum through the umbilical cicatrix is a safe and rapid technique.