A 23-year-old woman was admitted to the obstetric ward at 37 weeks in her fourth pregnancy. She complained of colicky generalized abdominal pain and nausea for 6 h before her admission. The antenatal period had been uneventful. On examination the uterus was not tender, consistent with 37 weeks gestation, and a fetal heart beat was present. There was tenderness on palpation in the epigastrium and right hypochondrium, but there was no abdominal guarding and normal bowel sounds were present. Her pain settled but returned 48 h later with vomiting of bile-stained fluid. Biliary colic was diagnosed. A full blood count, plasma electrolytes and serum amylase were normal and a plain abdominal X-ray showed no abnormality. She was treated with intravenous fluids and again her symptoms quickly settled. Four days after admission an ultrasound examination was performed. This showed a normal gall bladder, liver and kidneys but also revealed an elliptical cystic mass extending from the renal angle into the right iliac fossa. The nature of the mass was uncertain but it was considered that it might be dilated loops of small bowel. The patient remained asymptomatic. A week after admission she developed a further recurrence of right sided upper abdominal pain and vomiting. At the time she also reported reduced fetal movements. Cardiototography showed diminished baseline variability and reduced fetal movements. Because of the abnormal fetal heart trace, labour was induced and 1 h later, at only

Summary:A case ofperitonitis secondary to the perforation of a bronchogenic small bowel metastasis is reported. To our knowledge this is only the fourth case in which peritonitis was the presenting feature of a squamous cell carcinoma of the bronchus. The publications to date are reviewed and the need to biopsy every small bowel perforation found at laparotomy is stressed.

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A 31-year-old primigravid female presented to the obstetric department with severe left flank pain at 27 weeks' gestation. Her pregnancy had otherwise been straightforward and there was no significant past medical history. Physical examination was unremarkable apart from some vague tenderness and fullness in the left upper quadrant, and routine blood tests and urinalysis revealed no abnormalities. Obstetric ultrasound confirmed a 27-week gravid uterus with a single live fetus. Analgesia was administered and an ultrasound scan of her abdomen requested for the next morning. Over the next few hours her abdominal pain got progressively more severe and the patient became increasingly distressed. Further examination revealed her to be hypotensive (blood pressure 85/40 mmHg), tachycardic and tachypnoeic with obvious central cyanosis (SpO2 88% on room air). Auscultation of her chest revealed decreased air entry over the left lung and tracheal shift to the right. An urgent chest X-ray suggested left diaphragmatic herniation of abdominal contents (Figure 1). Insertion of a nasogastric tube was attempted without success. Owing to increasing hypoxia and respiratory distress a decision was made to intubate and ventilate the patient before transfer to theatre. Emergency laparotomy revealed at least 3.5 litres of blood within the peritoneal cavity and a large congenital defect in the postero-lateral portion of the left hemi-diaphragm (Bochdalek hernia). Most of the small bowel, the whole of the transverse colon and the stomach with the attached spleen had herniated through the defect causing the left lung to collapse. The abdominal contents were reduced back into the abdominal cavity, and the diaphragmatic defect repaired. A dead fetus was removed by caesarean section. The patient required several weeks of intensive therapy, and her recovery was complicated by pancreatitis which required laparotomy for desloughing of necrotic pancreatic tissue. She eventually went on to make a full recovery, and has subsequently had a healthy baby.

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