SummaryWe describe a patient who presented with iron deficiency anaemia in whom both upper and lower gastrointestinal investigation were initially negative. Management included successive blood transfusions. Repeat investigation six months later revealed caecal adenocarcinoma. At laparotomy, the patient was also found to have two separate primary synchronous adenocarcinomas of the proximal small bowel. Right hemicolectomy and excision of the small bowel lesions were carried out. The patient eventually succumbed to the disease six weeks after discharge from hospital.

This case describes a rare presentation of Crohn's disease and highlights the need to consider underlying gastrointestinal pathology in patients presenting with a deteriorating clinical condition in the presence of an incidental foreign body.

An 85-year-old man was referred to our department, with a three-day history of increasing shortness of breath. Following clinical and radiological assessment, diaphragmatic herniation of bowel was identified to be causing mediastinal shift and respiratory distress. An emergency laparotomy identified a massive diaphragmatic defect which was not amenable to primary closure. A colopexy procedure was performed to comparmentalise the abdomen and obliterate the diaphragmatic defect. Despite aggressive treatment in the intensive care unit he died from multi-organ failure. This case highlights an extremely rare and life-threatening cause of mediastinal shift and respiratory distress.

Summary. We reportan unusual case of heterotopic gastric mucosa causing chronic painful perianal ulceration. This condition is of interest asa rare cause of perianal ulceration, pain and rectal bleeding and the definitive treatment is usually surgical excision.