AimThe aim of this study was to investigate the microbiology of secondary bacterial peritonitis due to appendicitis and the appropriateness of current antimicrobial practice in one institution.MethodsA 14-year retrospective single-centre study of 69 consecutive paediatric patients (age 1–14 years) with appendicitis-related peritonitis and positive peritoneal specimen cultures was conducted. Post-operative outcomes, microbiology and antibiotic susceptibility of peritoneal isolates were analysed in all patients.ResultsEscherichia coli was identified in 56/69 (81 %) peritoneal specimens; four isolates were resistant to amoxicillin–clavulanate, and one other isolate was resistant to gentamicin. Anaerobes were identified in 37/69 (54 %) peritoneal specimens; two anaerobic isolates were resistant to amoxicillin–clavulanate and one isolate was resistant to metronidazole. Pseudomonas aeruginosa was identified in 4/69 (6 %) peritoneal specimens, and all were susceptible to gentamicin. Streptococcal species (two Group F streptococci and three β-haemolytic streptococci) were identified in 5/69 (7 %) specimens, and all were susceptible to amoxicillin–clavulanate. Combination therapy involving amoxicillin–clavulanate and aminoglycoside is appropriate empirical treatment in 68/69 (99 %) patients. Addition of metronidazole to this regime would provide 100 % initial empirical coverage. Inadequate initial empiric antibiotic treatment and the presence of amoxicillin–clavulanate resistant E. coli were independent predictors of the post-operative infectious complications observed in 14/69 (20 %) patients.ConclusionE. coli and mixed anaerobes are the predominant organisms identified in secondary peritonitis from appendicitis in children. Inadequate initial empirical antibiotic and amoxicillin–clavulanate resistant E. coli may contribute to increased post-operative infectious complications. This study provides evidence-based information on choice of combination therapy for paediatric appendicitis-related bacterial peritonitis.

Independent clinical predictors of advanced appendicitis exist but lack individual accuracy. In this study, preoperative pyrexia is shown to be highly associated with both advanced appendicitis and development of postoperative complications. This independent factor may point to early need for antibiotic treatment, urgent imaging and subsequent intervention in patients with appendicitis.

Recurrent Rapunzel syndrome (RRS) is a rare clinical presentation with fewer than six cases reported in the PubMed literature. A report of RRS and literature review is presented. A 25-year-old female was admitted to hospital with a 4-wk history of epigastric pain and swelling. She had a known history of trichophagia with a previous admission for Rapunzel syndrome requiring a laparotomy nine years earlier, aged 16. Psychological treatment had been successfully achieved for nine years with outpatient hypnotherapy sessions only, but she defaulted on her last session due to stressors at home. The abdominal examination demonstrated an epigastric mass. Computer tomography scan revealed a large gastric bezoar and features of aspiration pneumonia. The patient underwent emergency open surgical laparotomy for removal as the bezoar could not be removed endoscopically. The bezoar was cast in a shape that mimicked the contours of the stomach and proximal small bowel, hence the diagnosis of RRS. The patient was seen by a psychiatrist and was commenced on Quetiapine before discharge. She continues to attend follow-up.

CRP is effective as an early predictor of infective complications after laparoscopic colorectal surgery and may be a useful adjunct in conjunction with an enhanced recovery program in reducing morbidity. A CRP of >148 mg/mL on postoperative day 3 or a persistently elevated CRP should heighten clinical suspicion of an infective complication.

HighlightsEndoscopic removal of mobile phones in the stomach may be challenging.“Safe” removal may not be achieved using current retrieval devices.Patients consented for removal under general anaesthetic should be consented for laparotomy.Improvement in existing endoscopic retrieval devices are needed to manage similar cases.

Retained foreign bodies within the gastrointestinal tract (GIT) are common emergency presentations. The majority will pass spontaneously or be removed endoscopically, but a few selected cases may require emergency surgery for removal. This chapter reviews the management of foreign bodies within the GIT including both instances of foreign body ingestions and foreign body insertions. The scope of this chapter is not limited to evidence-based data on selection of cases for conservative management but also includes data on endoscopic and surgical management.

HighlightsA case of a 68-year-old male with large bowel obstruction due to the presence of a phallic object in the rectum is presented.Removal of the phallic object was achieved using a pair of Magill’s forceps and bi-manual manipulation under general anaesthesia.This case demonstrates the use of Magill’s forceps to aid removal of a foreign body in the rectum.Laparotomy and open removal may, therefore, be rarely necessary.

In peritoneal dialysis, a well-functioning catheter is of great importance because a dysfunctional catheter may be associated with exit-site infection, peritonitis, reduced efficiency of dialysis, and overall quality of treatment, representing one of the main barriers to optimal use of peritoneal dialysis. This chapter reviews the literature on indications and contraindications for peritoneal dialysis, peritoneal dialysis catheter design and materials, the techniques of insertion, complications, and method of removal of dialysis catheters.