Pneumatosis intestinalis (PI) is a condition characterised by gas-filled cystic malformations on the intestinal wall. It is often secondary to an underlying disease process. We describe the case of a 76-year-old gentleman who presented with intermittent abdominal pain, altered bowel habits and weight loss. Barium enema was unremarkable, apart from sigmoid diverticulosis. CT scan found evidence of pneumatosis on small bowel walls with benign pneumoperitoneum. As there was no sign of intra-abdominal crisis, he was initially treated conservatively. Unfortunately, he required re-admission 6 weeks later with symptoms of bowel obstruction and clinical signs of perotinitis. At laparotomy, he was found to have extensive small bowel infarction due to volvulus from 'twisting' around the axis of superior mesenteric vessels. Evidently, this occurred secondary to a congenitally long small bowel mesentery that predisposed him to volvulus. Extensive small bowel resection was performed. The postoperative course was complicated by persistent hypotension, which proved fatal. This case report draws attention to the rare association between PI and small bowel volvulus predisposed by a congenitally long mesentery, which can present initially with a benign picture (intermittent, reversible volvulus), but subsequently be complicated by lethal bowel infarction (irreversible volvulus). This case raises several issues about the management of this rare condition. Clinicians must realise that PI, though often benign, can present with lethal complications, and early recognition of such complications can be life-saving.

Cholecysto-duodenal fistula and gallstone ileus are well-recognised complications of gallstone disease. However, small bowel necrosis is a rare complication of gallstone disease. We describe a case of gallstone-induced ileal necrosis presenting with symptoms and signs resembling acute appendicitis. A 79-year-old woman presented to the surgical team with central abdominal pain which subsequently shifted to the right iliac fossa. Clinically, the patient had localised perotinism in the right iliac fossa with high inflammatory markers. Abdominal radiography showed no diagnostic features. Initial clinical impression was that of acute appendicitis. Given that this diagnosis was unlikely in a patient of this age, an abdominal CT scan was performed. The CT scan showed evidence of a large gallstone causing small bowel obstruction in the presence of a cholecysto-duodenal fistula. At surgery, she was found to have an area of necrosis with a pin-point perforation at the site of impaction of the gallstone in the proximal ileum. This occurred secondarily to pressure necrosis from the gallstone impacting at a site where the small bowel diameter narrows in transition from jejunum to ileum. A limited small bowel resection was performed with an uncomplicated postoperative course. This case report draws attention to a rare complication of gallstone disease which presents with a clinical picture similar to acute appendicitis. Preoperative investigation for an elderly patient who presents with an acute abdomen should include an abdominal CT scan to diagnose any rare disease processes which otherwise may not be suspected.