IntroductionGastrointestinal perforation due to a foreign body is not unknown. The foreign body often mimics another cause of acute abdomen and requires emergency surgical intervention. The majority of patients do not recall ingesting the foreign body. Perforations have been reported to occur in a pathologically abnormal colon.Case presentationWe report an interesting case of a 47-year-old Caucasian man who had a perforation of the sigmoid colon caused by an ingested chicken bone mimicking acute appendicitis. Our patient presented with right iliac fossa pain and local tenderness. When a laparotomy was performed, a chicken bone was found protruding through the sigmoid colon, which was found to lie in the right iliac fossa, thus mimicking acute appendicitis. Our case is different from previously reported cases in that perforation occurred in a non-pathological colon.ConclusionOur case emphasises the fact that the operating surgeon has to be aware of various differential diagnostic possibilities which mimic acute appendicitis. This has implications on the training of junior surgeons who are often involved in performing these procedures, and may do so out of hours. Care needs to be taken while obtaining consent for the necessary operation.
Background. With the increase in bariatric surgery in the UK, there has been a substantial increase in patients undergoing massive weight loss (MWL) seeking postbariatric body-contouring (bariplastic) surgery. However, there is a wide variation of availability on the National Health Service (NHS). Aims. To (1) review the funding policies of Primary Care Trusts (PCTs) in England for bariplastic surgery and (2) analyse the number of procedures funded in two consecutive financial years. Methods. We sent out questionnaires to all PCTs in England regarding their funding policies for bariplastic surgery and requested the number of procedures funded in 2008-09 and 2009-10. Findings. 121/147 (82%) PCTs replied to our questionnaires. 73 (60%) excluded all bariplastic procedures. 106/121 (87.6%) PCTs had referral guidelines for plastic surgery. 46/121 (38%) PCTs provided the total number of funded abdominoplasty-apronectomy (A-A) in the two financial years: total number of A-A applicants rose from 393 to 531, but approval for funding fell from 24.2% to 19.6%. Only 3 (2%) PCTs indicated increase in their future spending on bariplastic procedures in the next 5 years, with 67% planning to decrease or unsure about future funding. Conclusion. There exists a postcode lottery for bariplastic surgery in England and we feel the need for guidelines on provision of bariplastic procedures following MWL.
SummaryA 45-year-old Afro-Caribbean woman attended the emergency department with worsening dysphagia, abdominal distension, abdominal pain, shortness of breath and generalised weakness. She enjoyed preparing and eating cows-feet stew and preferred to cook the meat with the hair and skin intact. On admission she had a severe microcytic anaemia and was malnourished. Abdominal x-ray and CT revealed a large gastric bezoar. At gastrotomy a foul-smelling 2.42 kg mass of hair, leathery skin and altered food were evacuated from the lesser curvature of the stomach. She had undergone the same procedure 8 years earlier to remove a similar trichobezoar.Following psychiatric review it was deemed that the patient had no underlying psychiatric condition and had full insight into why her trichobezoar had re-occurred. She made a good postoperative recovery and stopped eating cows-feet stew. BACKGROUND
We present the unusual case of a woman presenting with an incarcerated umbilical hernia. Intraoperatively, the contents of the hernia were found to be an ovary. We outline the clinical presentation of our patient, investigations and management as well as a discussion on unusual contents of umbilical hernias. To our knowledge, this is the first case of a non-malignant ovary incarcerated in an umbilical hernia. KEYWORDSHernia -Umbilicus -Surgical mesh -Ovary Accepted 6 September 2013; published online XXX CORRESPONDENCE TO Usama Ahmed, E: usama.x@hotmail.fr Umbilical hernias are common, occurring in 10% of all infants.1 In adults, however, they often represent an acquired defect, possibly related to intra-abdominal pathology. We present our own experience of unusual contents of an umbilical hernia, its management and a brief literature review. Case HistoryA 45-year-old nulliparous woman of Zimbabwean origin presented to our emergency department complaining of a 5-day history of an increasingly tender, swollen, irreducible mass at the umbilicus. On further enquiry, it transpired that this previously reducible mass had been present for approximately one year's duration, tender during her periods but otherwise asymptomatic. She reported regular, heavy periods with clots and flooding, and denied possible pregnancy. Her only past medical history was of a myomectomy for a uterine fibroid 11 years earlier. She denied a previous history of a childhood umbilical hernia. On systems review, she had no weight loss or loss of appetite. She had been opening her bowels normally, had not vomited, and was eating and drinking normally. On examination, the patient was haemodynamically stable and clinically well. Her abdomen was distended and a tense umbilical mass visible with overlying inflammatory hyperpigmented skin changes. Palpation of the abdomen revealed a tender, irreducible umbilical mass with a negative cough impulse. Abdominal ascites were absent. An irregularly contoured, 20-week sized fibroid uterus reaching the umbilicus and more palpable in the right abdomen was discovered.Blood tests revealed raised inflammatory markers and severe anaemia. The patient was transfused with two units of blood preoperatively and iron supplements were commenced. Erect abdominal radiography revealed no acute obstruction or perforation.Our main differential diagnosis was that of an incarcerated umbilical hernia with a differential of an abscess. The patient was consented for repair of umbilical hernia and operated on later that evening. A curvilinear subumbilical incision was used to approach the hernia. A true umbilical hernia coming through the umbilical stalk was visualised. The hernial sac was opened at the neck to reveal an ovary (Fig 1). The ovary was seen to be viable and so reduced through the defect. The defect was closed with an onlay polypropylene mesh and a suction drain left in situ. Postoperative ultrasonography showed multiple uterine fibroids with the largest measuring 8.6cm in diameter (Fig 2). The patient was disch...
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