The first recorded case of a total cast of the left hemicolon being passed spontaneously, per anus, without the development of peritonitis, is presented. Case reportA 64-year-old man presented with a 2 week history of sudden onset of central abdominal discomfort, watery diarrhoea and anorexia, with weight loss of approximately 3 kg. Examination revealed an unwell man, dehydrated, mildly icteric, with a low grade pyrexia and tachycardia. Abdominal examination was uncomfortable and revealed a slightly enlarged liver, a non-tender 6 cm abdominal aortic aneurysm and normal bowel sounds. On rectal examination, a firm ridge could be felt at 6 cm, suggestive of a carcinoma. Sigmoidoscopy, however, revealed a normal 6 cm rectal cuff, above which was blackened mucosa, with yellow watery fluid filling the lumen.An electrocardiograph showed changes consistent with a recent (asymptomatic) inferior myocardial infarction. Biochemistry revealed a raised urea (19.5mmol/l) (normal range 3.(&7.5mrnol/l) and creatinine (207pmol/l) (normal range 53-120pmol/l) and a moderate rise in bilirubin and liver enzymes. He had a normal haemoglobin, an ESR of 80 mm/h and a white cell count of 1 9 . 7~ 109/1 with neutrophilia (87 per cent). Stool culture did not grow any pathogens. A provisional diagnosis of ischaemic colitis was made and the patient was treated expectantly.He remained pain free with normal bowel sounds, his diarrhoea became less frequent and his hydration quickly improved. Biochemically his renal function became normal, and his liver function tests improved.On the seventh day after admission he suddenly and spontaneously passed 96 cm of a full thickness necrotic large bowel cast per anum.His discomfort left him and, clinically, his condition was unchanged. He had a non-tender abdomen and normal bowel sounds. Sigmoidoscopy revealed a granulation tissue lined tract, extending up from the rectal cuff, fully of watery yellow fluid. Plain supine abdominal X-ray demonstrated a normal large bowel gas pattern up to the splenic flexure, after which there was a linear gas shadow extending down deep into the pelvis ( Figure I). His white cell count was 8 . 4~ 109/1 and histology of the bowel revealed it to be a full thickness necrotic cast of the colon. Fifteen hours later and still well having passed flatus, the patient was taken to theatre and explored through a midline incision. At laparotomy, the left colon tract was found to be completely excluded from the general peritoneal cavity by omentum and small bowel adhesions. There was a 6 cm diameter infrarenal abdominal aortic aneurysm with no pulse in the inferior mesenteric artery. The left colon's track was widely laid open and drained and the transverse colon was brought out as an end colostomy. The short rectal cuff that remained was left open to drain.Postoperatively the patient's recovery was uncomplicated and he was discharged on the twelfth postoperative day. On the fiftieth postoperative day he had a straight Dacron graft replacement of the abdominal aortic aneurysm and remains...

Valvular vegetation is known to occur rarely in scleroderma since the first description by Spuhler and Morandi", They described pea-sized, non-bacterial mitral vegetation at autopsy in a case of scleroderma, with evidence of renal and cardiac embolism. The vegetation was thought to be the counterpart of the verrucous endocarditis of Libman and Sacks, a view echoed by Oram and Stokes" who found five cases of valvular vegetation in 28 autopsy cases of scleroderma heart disease. There was no mention of embolism from these lesions in the latter report however, and because there have been no clinical reports of embolism from vegetation in scleroderma, a recent review has concluded that these lesions are without clinical significance'. It is, however, likely that our patient had systemic embolism from vegetation similar to those described in the reports mentioned above z. 6 • Valvular vegetation is a poorly known complication of scleroderma, and is probably the counterpart of Libman-Sacks endocarditis in systemic lupus erythematosus.

Two forms of bowel preparation for colonoscopy were compared--19 patients were given 5 per cent mannitol solution orally while a further 19 were infused with isotonic saline via a nasogastric tube. Both methods proved equally acceptable to the patients and endoscopists. Saline led to a rise in body weight (+0.75 +/- 0.35 kg) and blood pressure (+7.5 +/- 2.8 mmHg) while mannitol caused a significant fall in both body weight (-0.74 +/- 0.28 kg) and blood pressure (-3.8 +/- 2.9 mmHg). Plasma volume measurements were carried out on 17 patients; 8 receiving saline showed a rise (+0.22 +/- 0.08 l) while 9 taking mannitol experienced a fall (-0.17 +/- 0.08 l). Twelve further subjects prepared with a combination 10 per cent mannitol and isotonic saline showed a small fall in plasma volume (-0.08 +/- 0.05 l). Mannitol proved an acceptable preparation for colonoscopies but a fall in body weight, blood pressure and plasma volume posed a small risk to the elderly subject and in view of the known risks of mannitol during diathermy this form of preparation was not considered a suitable alternative to isotonic saline.

Palliative treatment of an enterovaginal fistula secondary to adenocarcinoma of the rectum in a 65-year-old woman with intraperitoneal corium porcine graft is reported. The patient had previously had a total colectomy for ulcerative colitis followed by excision of the rectal stump, mucosal proctectomy and ileostomy.