Pneumomediastinum without trauma or clear secondary cause is called Spontaneous pneumomediastinum with an incidence between 0.001%-0.014% and most commonly seen in young males. Marijuana smoking has rarely been identified as a possible cause of spontaneous pneumomediastinum, which is likely caused by barotrauma during breathing manoeuvres. Fewer than 10 case reports have been reported in the literature on Marijuana causing Spontaneous pneumomediastinum. We present a 24year male who presented with dysphagia, swelling and crackling under the skin of his neck for the past 12hours, half an hour after blowing his nose. There was no chest pain or dyspnoea, and he was hemodynamically stable with normal blood investigations. He smokes cannabis regularly and occasionally does cocaine. On examination, surgical emphysema was felt on both sides of the neck; the systemic examination was unremarkable. CT thorax demonstrated extensive pneumomediastinum and surgical emphysema from the angle of the jaw throughout the neck and down to the right subcapsular region. No pneumothorax was seen, and lung parenchyma was unremarkable. However, to rule out the clinical suspicion of oesophageal rupture, he had a CT oesophagus with oral contrast, which showed no extravasation of contrast from the oesophagus. The patient was admitted for observation, and the Chest X-ray after 12hours dint show pneumothorax. He was clinically well, tolerating oral feeds, so he was discharged with oral antibiotics as a prophylactic cover as per UGI surgeons. The knowledge about this rare cause would help the physicians diagnose and educate the patients on the risk involved in using Marijuana.

Video S1. Robotic right hemicolectomy with D3 lymphadenectomy, complete mesocolon excision and intracorporeal anastomosis. Data S1. Typed script of the video.

We present a 90year old male patient presenting to the emergency department with complaints of PR bleed for a month with no associated abdominal pain. He described that the blood was mixed with stools and dark in colour. He has a significant past medical history with multiple comorbidities. The patient is known to have gallstones and had ERCP with sphincterotomy in 2017 as a definitive treatment, as he wasn’t a fit candidate for surgical intervention. On clinical examination, his abdomen was soft and non-tender and per rectal examination showed stools mixed with the blood but no active bleeding or fresh blood. His haemoglobin was 72 g/L, inflammatory markers were significantly elevated with deranged liver enzymes and normal bilirubin. The medical team were involved in the management of this patient because of pneumonia and extensive medical issues. A gastroscopy was performed as there was a suspicion of UGI bleed, which was normal. Given a deranged liver function and there was a suspicion of biliary sepsis patient had MRCP and Computed tomography of the abdomen which confirmed that there is haematoma in the gallbladder with gas in the biliary tree, with possible cholecysto-colonic fistula, with a large gall stone (2.7cm lamellated structure within rectum) in the rectum. As the patient was not a surgical candidate decision was made to manage him conservatively with antibiotics under medical care. The cholecysto-colonic fistula is a rare complication of gallstone disease, and very few cases have been reported in the literature.

Introduction The small bowel obstruction in a non-operated abdomen is rare, and the most common causes are hernia and neoplasm. The complete mechanical small bowel obstruction due to an omental band in a patient with no previous abdominal surgery is rare, and less than five cases have been reported in the literature. Case presentation We report a 65 year old male patient presented to the emergency department with complaints of abdominal pain, distension, vomiting and obstipation for four days. On clinical examination, his abdomen was distended, diffusely tender, guarding. The blood investigations showed elevated White blood cells and neutrophils with normal CRP and the Serum lactate. The Abdominal X-ray was suggestive of SBO. The Computed tomography of the abdomen and pelvis showed marked dilatation of the jejunum, the ileum is entirely collapsed, the impression of a double beak sign in the mid-abdomen which would suggest closed-loop obstruction due to a possible internal hernia. We proceeded with emergency diagnostic laparoscopy converted to laparotomy, which showed omental band causing closed-loop proximal small bowel obstruction. The bowel loops appeared congested with the constriction band due to omental band. The omental band was divided, and the obstruction was relieved. Postoperatively patient recovered well and was discharged on day three post-op. Discussion The timely diagnosis and intervention could prevent complications like strangulation, ischemia and gangrene. Though the omental band is rare, it should still be suspected as an aetiology in patients without prior abdominal surgery.