Figure 1 Chest radiograph at presentation. right ovarian pathology compatible with Meigs' syndrome.Two years previously she had presented with a burst chocolate cyst. Laparoscopy was performed, the cyst was removed, and a diagnosis of endometriosis was made from laparoscopic appearances, although no endometrial tissue was found in the biopsy samples. She was treated for endometriosis with danazol for nine months and remained well until she presented with the ascites and pleural effusion.Diagnostic aspirates revealed chocolate coloured ascitic fluid and bloodstained pleural fluid, both exudates. Bacterial and tuberculosis cultures were negative, and the pleural fluid alpha-fetoprotein (AFP) and human chorionic gonadotrophin (HCG) levels were normal. Cytological examination of the pleural fluid showed poorly differentiated adenocarcinoma cells; ascitic fluid cytology was negative. Three litres of bloodstained pleural fluid were drained from the chest. Bronchoscopic examination was normal and medial thoracoscopy showed a normal pleural cavity with no evidence of pleural endometriosis and pleural biopsy samples were normal. Sputum culture and cytology was negative. At presentation full blood count, ESR, clotting screen, routine biochemistry, thyroid function, serum complement levels and immunoglobulins were all normal. HIV and hepatitis B serology was negative, and Tine test grade 2. Carcinoembryonic antigen (CEA) levels were normal, but the CA-125 antigen level was slightly raised at 49 kU/ 1 (upper limit of normal 35).Laparoscopy showed minimal endometriosis, a left ovarian mass, and perihepatic adhesions. Laparotomy was performed in view of the apparent ovarian mass and the left ovary was removed and a right ovarian wedge biopsy sample was taken. Histological examination showed normal ovaries and peritoneal endometriosis. A six month course of the gonadotrophin releasing hormone (GnRH) agonist leuprorelin acetate was given for endometriosis.Pleural and ascitic aspirates performed twice over the next year showed no growth on bacterial and tuberculosis cultures and the results of cytological examination were negative. Several pleural biopsy specimens revealed no evidence of malignancy. Repeat surgical thoracoscopy performed at another hospital was normal, and surgical pleurodesis was performed. The pleural fluid reaccumulated over the next eight months.Two years after presentation she still had a right pleural effusion, a pericardial effusion, and marked ascites. Pleural and ascitic fluid cultures for bacteria and tuberculosis were negative, and cytological examination revealed no neoplastic cells. Four litres of bloodstained pleural fluid were aspirated. Pleural biopsy samples showed fibrous thickened pleura and one possible granuloma, ZN stain for tuberculosis was negative, and bronchoscopic examination was normal.A one month trial of prednisolone 30 mg per day had no effect on the fluid accumulation. The investigations were repeated and bacterial, tuberculous, and fungal cultures and cytology 1 062 on 9 May 201...

(FEV,) of 15 1 and a forced vital capacity (FVC) of 2 55 1. Although the tumour was resectable, pneumonectomy was considered to be too hazardous in the presence of severe coronary artery disease, and coronary artery surgery was precluded by the combined risks of haemorrhage from the tumour and postoperative pneumonia in the obstructed lung.In an attempt to improve the patient's fitness for cardiac surgery, endobronchial tumour was resected with a neodymium YAG laser operating at a wavelength of 1-32 gm (MBB-Medilas 2, Medizintechnic). Treatment was given at power settings of 10-20 watts in pulses of up to one second.3 An airway was restored to the left lower lobe and a large volume of mucus and altered blood was drained; all bleeding points on the tumour bed were then cauterised. Treatment was given under general anaesthesia with full invasive monitoring. Cardiovascular stability was maintained throughout the procedure.Nine days later vein grafts were applied to the left anterior descending and right circumflex coronary arteries. The operative course was uneventful with no bleeding from the tumour. During the immediate postoperative period he developed complete collapse of the left lung and became hypoxic despite ventilatory support (arterial oxygen tension (Pao2) 7-9 kPa with 80% oxygen). A fibrin plug occluding the left main bronchus was removed with a fibreoptic bronchoscope. The lower lobe re-expanded with immediate improvement in oxygenation (Pao2 25 kPa with 70% oxygen) and he was weaned from ventilatory support. Respiratory function tests performed on the eighth postoperative day showed an FEV, of 25 1 and an FVC of 36 1, indicating a considerable improvement.Pneumonectomy was planned after an interval of four to six weeks. He developed a haematoma in his left leg, however, at the site of his vein surgery, which became infected with methicillin resistant Staphylococcus aureus. His pneumonectomy was postponed for six months until the infection had resolved. Repeat staging confirmed that the tumour was resectable. A left pneumonectomy was performed without complication. Mediastinal lymph nodes were sampled at the time of surgery and were found to be free from tumour. Examination of the resected specimen showed that the hilar glands were also free from tumour, though the bronchial lymph nodes were directly affected; thus he had T2N,MK stage disease.4 The patient has remained well without clinical or radiological signs of recurrence for 27 months. During this time he has been able to lead an active and independent life. Discussion

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A 58-year-old man presented acutely with features of post-surgical adhesive small bowel obstruction. Following an unsuccessful trial of conservative management, computed tomography (CT) of the abdomen was performed. This revealed a mass in the ileocaecal region, for which he underwent a subsequent right hemicolectomy. Histology revealed diffuse B-cell Non-Hodgkin’s lymphoma of the terminal ileum. Confounding obstructive lesion of the intestine in patients with a history of previous laparotomy is extremely uncommon. Early high resolution imaging may predict diagnosis and consolidate clinical management plans.