IntroductionIntramural oesophageal dissection (IOD) is a rare clinical condition and there is a paucity of information regarding the appropriate diagnosis and management. It is described as bleeding in the submucosal plane of the oesophagus, and has various documented causes.Presentation of caseWe report a case of a 73 year old female who developed IOD. She presented with severe chest pain. Subsequent imaging revealed IOD and haematoma formation. This was confirmed on oesophagogastroduodenoscopy (OGD). She was on a bisphosphonate for her osteoporosis, as well as having age-related dysmotility of her oesophagus on manometric studies. She was also taking fish oil. Treatment was conservative and the patient was discharged with proton pump inhibitors and follow up.DiscussionSpontaneous haematoma formation and IOD resulted likely from a combination of the anticoagulant effect of fish oil and oesophageal dysmotility. Bisphosphonates also have some well documented gastrointestinal side effects involving mucosal damage. The possibility that the concurrent use of bisphosphonate led to a pre-existing ulcer which could have contributed to the development of IOD in this patient should be considered.Conclusionspontaneous IOD can occur in elderly patients who are anticoagulated. Fish oil has not been previously reported as having an association with IOD. This is the first known reported case of spontaneous IOD occurring in association with concurrent use of a bisphosphonate and fish oil. IOD is a rare disorder, and any anticoagulated patients presenting with severe chest pain may need careful investigation prior to definitive management.

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A 39-year-old female presented to a regional Australian hospital with diabetic ketoacidosis. Urine microscopy, culture and sensitivity (MCS) on arrival revealed 500 leukocytes and eventually culture grew pansensitive E. coli. Patient was transferred to ICU for ongoing care where she remained tachycardic despite resolution of her diabetic ketoacidosis. A CT pulmonary angiogram was performed which found a right lower lobe pulmonary embolus for which therapeutic anticoagulation was commenced. However, tachycardia persisted and the patient became febrile on day three of admission. A CT abdomen pelvis was performed which revealed left-sided emphysematous pyelonephritis secondary to a large staghorn calculus. Significant subcutaneous emphysema was also found in the left flank. A general surgery review was requested and the case was discussed with the urology team located at a tertiary centre. The patient was subsequently transferred to a tertiary hospital under urology where she underwent a left nephrectomy and wound debridement. This was complicated by colonic perforation and was repaired with an omental patch with a loop ileostomy formed. Patient underwent a total of six relooks and debridements before the wound was closed with a combination of delayed primary closure and split-thickness skin graft.