Gastric volvulus is a condition that is not frequently seen in clinical practice and can present with a myriad of symptoms, meaning it can be challenging to diagnose. We present an 82-year-old female attending the emergency department with epigastric pain and coffee ground vomiting on a background of rectosigmoid cancer and a large, complex hiatus hernia. On investigation there was no drop in haemoglobin. However, the chest X-ray showed air-fluid levels and raised the suspicion of gastric volvulus, particularly given her past medical history. The timely organisation of a computed tomogram (CT) scan allowed for prompt decision-making with involvement of surgical colleagues. The patient proceeded to successful conservative management with upper gastroduodenal endoscopy and a de-rotation technique. This case highlights the importance of considering gastric volvulus as a differential diagnosis in those presenting with epigastric pain and vomiting particularly in patients over 50 with a history of large hiatus hernia. This allows for prompt diagnosis and management and avoidance of major complications like gastric mucosal ischaemia.

Background: Pain is a very important factor in patient recovery and satisfaction. Following incision and drainage of perianal abscess, wound packing has been found to be very painful. The aim of this study is to compare packing the wound and not packing the wound after incision and drainage (I&D) of perianal abscess, taking into account recurrence rate, rate of occurrence of perianal fistula as well as post-operative pain. Materials and Method: Standard medical electronic databases were searched with the help of a local librarian and relevant published randomised controlled trials (RCT) were shortlisted according to the inclusion criteria. The summated outcome of post-operative pain score, recurrence rate, and rate of occurrence of perianal fistula was evaluated using the principles of meta-analysis on RevMan 5 statistical software. Result: Three RCTs on 490 patients undergoing I&D of perianal abscess were found suitable for this meta-analysis. In the random effects model analysis, the post operative pain score was statistically lower in NPG [risk ratio 0.66, 95%, CI (0.36, 0.97), Z=4.25, P=0.0001]. There was no heterogeneity [Tau2=0.15; chi2=9.32; df=6; I2=36 %; p=0.16] between the studies, however, statistically it was not significant. In addition, there was no statistical difference between the 2 groups in terms of recurrence of perianal abscess or the occurrence of perianal fistula [risk ratio 0.64, 95%, CI (0.31, 1.31), Z=1.23, P=0.22], [risk ratio 1.41, 95%, CI (0.89, 2.23), Z=1.47, P=0.14] respectively. Conclusion: Not packing the wound post I&D of perianal abscess is associated with significantly reduced VAS pain scores, which may result in improved recovery and patient satisfaction and has no effect on recurrence rate or the occurrence of perianal fistula. However, more RCTs recruiting a greater number of patients are required to endorse these findings.