The addition of transdermal nicotine to conventional maintenance therapy improves symptoms in patients with ulcerative colitis.

A 70-year-old woman was admitted to the emergency department with a 2-week history of pain in the upper abdomen, vomiting, fever and jaundice. She was also complaining of pale stool and dark urine. Subsequently she developed abdominal distension with colicky pain and absolute constipation. There was no history of previous biliary symptoms. On examination she was pale and tachycardic with a fever of 37.9°C. Abdominal examination revealed generalized abdominal distension with a tender mass at right upper quadrant and hyperactive bowel sounds on auscultation. Laboratory examination showed a white blood cell count of 15 600/mm3 (neutrophil 85%), bilirubin of 47mmol/litre, alkaline phosphatase of 220 U/litre with normal liver enzymes and amylase. Plain abdominal X-ray demonstrated pneumobilia and dilated small and large bowel loops suggestive of intestinal obstruction (Figure 1). An unprepared barium enema showed a large smooth filling defect in sigmoid colon with large bowel obstruction (Figure 2). A diagnosis of large bowel obstruction presumably caused by a gall-stone was made. Surgical treatment followed a period of physiological optimization. At laparotomy the abnormalities were large bowel obstruction caused by an impacted gall-stone in a section of sigmoid diverticular disease plus right upper quadrant mass. A sigmoid colectomy with removal of diverticular disease and the stone, then a primary anastomosis was performed. Exploration of right upper quadrant mass revealed an inflamed friable gall bladder with a fistula between its fundus and the transverse colon. A partial cholecystectomy was performed, the cystic duct closed in-situ and the defect in transverse colon was brought out as a loop colostomy. Her postoperative course was uneventful. Closure of colostomy was performed 3 months later and she made a full recovery.