Portal vein thrombosis (PVT) following sleeve gastrectomy is rare. There are limited documented cases within the literature. The presentation of PVT varies on a spectrum from mild non-specific abdominal symptoms to life endangering clinical emergencies. This is the case of a 58-year-old woman who presented to the surgical assessment unit with acute onset abdominal pain 2 weeks post laparoscopic sleeve gastrectomy for morbid obesity. The initial diagnosis was that of a gastric sleeve leak. The patient deteriorated clinically and underwent a CT scan of her abdomen. This revealed the presence of an acute thrombus filling the portal vein with extension into the superior mesenteric vein branches. There were radiological changes suggestive of acute small bowel ischaemia. The patient underwent a laparotomy in theatre and 50 cm of the necrotic small bowel was resected. Postoperative care was carried out in the intensive care unit for 15 days.

A 68-year-old man with expressive dysphasia presented with upper gastrointestinal haemorrhage, jaundice and abdominal pain. He was unable to tolerate ultrasound tranducer pressure. His oesophagogastroduodenoscopy (OGD) showed large blood clots in the stomach with blood trickling from the ampulla. An urgent CT angiogram demonstrated a 32 mm pseudoaneurysm within the gallbladder fossa. The patient subsequently underwent an endovascular embolisation of the pseudoaneurysm performed by the interventional radiology team.

Introduction It is well known that CO2 insuffl ation reduces pain during and after colonoscopy. However air insuffl ation is more popular probably due to limited randomised studies. 1 This study compares the effects of air and CO2 insuffl ation on pain during and after colonoscopy. Methods The study was conducted over a 3-month period and 126 patients were randomly assigned into CO2 or air insuffl ation groups. Discomfort scores during and after colonoscopy was recorded using the modifi ed gloucester discomfort score and factors infl uencing outcome such as sex, endoscopist grade, previous surgery and sedation were also considered. Results Of 126 in the study, air was used in 36 and CO2 in 90. The caecal intubation rate in CO2 was 95% versus 91% in the air group. Patients in the CO2 group had lower pain scores during the procedure compared to air. During the procedure, 51.6% CO2 versus 36.11% (Air) had no discomfort at all (score 1). Patients who had a score of 2, 3 were 46% Air versus 40% CO2. There was a higher pain score (4, 5) noted at 7% versus 2.7% (Air) noted mainly in females (83.3%). Postprocedure discomfort scores were almost equal noted to be 1.19 Air versus 1.06 at 1 h and 1.08 versus 1.00 CO2 at 2 h. A number of factors were taken into consideration to see whether this infl uenced discomfort scores. (1) Sex: 57 males and 69 females were in the study. Females had higher pain scores 31.34% versus 15.52% (males). However this was not statistically signifi cant using the Mann-Whitney test.(2) Sedation: Average sedation used, midazolam (M) 1.93 versus 0.67 mg CO2, Pethidine 9 versus 14 mg CO2, fentanyl 34 versus 17 mg CO2. Average top up sedation used was 0.02 versus 0.05 mg CO2 of M, Pethidine 0.69 versus 0.5 mg CO2 and fentanyl 2.5 mg top up for CO2 group versus no top up. (3) Previous surgery: Data for only 74 patients was available. Those patients who have had no previous surgery (n=50) appear to have lower discomfort levels, however data points for pelvic surgery were too few to come to a conclusion. (4) Endoscopist: Discomfort scores were higher in trainees (n=34) using CO2 than consultants (n=56). Using MannWhitney test this was statistically signifi cant with a CI of 95.1%. There was no difference in scores in air group. In the consultant group, using CO2 lowered patient discomfort compared to air (p=0.06) that was statistically signifi cant.

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