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Fig. 3. Intraoperative retrograde pyelogram showing a tortuous left ureter travelling inferiorly.

Synchronous malignancies of the bile duct and the gallbladder are rare. These cases are often associated with pancreaticobiliary maljunction which is characterized by a long common shared pancreatobiliary channel leading to the Sphincter of Oddi. This predisposes the biliary epithelium to pancreatic enzyme reflux and makes the development of neoplasia more likely. We describe the case of a 64-year-old Caucasian female who presented with new jaundice and severe cholecystitis secondary to an impacted gallstone which was seen on ultrasound. Magnetic resonance cholangiopancreatography was organized with suspicion of a possible Mirizzi syndrome. This revealed a mid-distal bile duct cancer in addition to cholecystitis from an impacted gallstone. She was treated with intravenous antibiotics for her cholecystitis and underwent an urgent endoscopic retrograde cholangiopancreatography procedure for biliary decompression and stenting for her obstructive jaundice. The patient proceeded to pancreaticoduodenectomy with final histopathology revealing a synchronous primary gallbladder malignancy in addition to the known bile duct cancer.

A 77-year-old man presented with watery, bloody diarrhoea, symptomatic anaemia and signs of sepsis. He was well known to our unit with a history of extensive low-grade urothelial carcinoma involving a solitary kidney. CT performed on admission demonstrated a new finding of renocolic fistula. Due to his multiple medical and surgical comorbidities conservative management was elected. He passed away after 1 year of follow-up.

Fig. 3. Duplex ultrasound of the portal vein, which appears occluded with hypoechoic thrombus and no perfusion can be demonstrated with colour Doppler study.

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exceeding the FDA label recommendations of ADA 40 mg biweekly, ETN 50 mg weekly, and UST 45 mg every 12 weeks. RESULTS: In total, 15,400 PsA patients and 40,545 PSO patients met the inclusion criteria. The number (proportion) of patients receiving increased maintenance doses for PsA was1,603 of 8,908 (18%) for ADA and 1,300 of 7,647 (17%) for ETN. The number (proportion) of patients receiving increased maintenance doses for PSO was 3,187 of 21,234 (15%) for ADA; 5,201 of 16,318 (32%) for ETN; and 3,136 of 6,915 (45%) for UST. CONCLUSIONS: A large subgroup of patients treated with commonly used biologic agents is maintained on increased maintenance doses.

A De Garengeot hernia is the eponymous name to describe a femoral hernia containing the appendix. Imaging may confirm the diagnosis pre-operatively; however, many are identified at the time of surgery. We describe the case of an elderley female patient who presented with a small bowel obtruction due to an incarcerated femoral hernia, with the unexpected finding at the time of surgery of the appendix additionally within the hernia. Following diagnostic laparoscopy, she underwent a laparoscopic appendicectomy and open suture repair of the femoral hernia.