No abstract

Actinomycosis of the abdominal wall is a rare disease. While most of the reported cases are women, we present a 42-year-old male with an abdominal mass for 4 months. Clinical examination of the abdomen revealed a well circumscribed mass in the left iliac fossa. CT abdomen showed an anterior abdominal wall mass with infiltration to the sigmoid colon however colonoscopy ruled out intraluminal origin. In contrast to traditional open approach, a laparoscopic approach was done. The abdominal wall tumour and sigmoid colon was resected en- bloc and continuity restored extra- corporeally through a small incision. Histopathology of the specimen reported an abdominal wall actinomycosis and patient was discharged with antibiotics. Laparoscopic approach was successful as the tumour was small. We therefore conclude that an initial laparoscopic assessment can be advocated and a laparoscopic excision is always possible if the features are favourable.

Small bowel bleed accounts for approximately 5% of all gastrointestinal bleeding. While arteriovenous malformation is the commonest cause of small bowel bleeding, other causes include inflammatory bowel disease, small bowel tumours, ulcers and polyps make up the rest. Tumours range from benign adenomas, hamartomas and leiomyomas to malignant GISTs, adenocarcinomas or lymphomas. We reported a case of a jejunal GIST causing intermittent bleeding. Upper and lower GI endoscopy did not find any abnormality and the diagnosis was made through computerized tomography. It showed a mid-jejunal tumour that was in close proximity to the distal duodenum. The rest of the hollow and solid organs were normal. The patient was prepared and underwent laparoscopic assessment. The tumour was mobile, arising from proximal jejunum and did not show infiltration or adhesions to nearby viscera. A segmental resection with adequate margin was performed laparoscopically and extracted through the umbilical port wound. The pathology report revealed an intermediate GIST with clear margins. Laparoscopic assessment should ideally be carried prior to any resection of small bowel tumours. Uncomplicated small bowel resections can safely be done laparoscopically with good oncological outcome and faster patient recovery.

Gallstone ileus (GSI) is a mechanical intraluminal bowel obstruction caused by biliary calculi through the biliary-enteric fistula. This is a rare sequela of cholelithiasis occurring in 0.3 – 1.5% of patients with worrying mortality of 11.7 – 20%. This is a case of GSI in a 67-year-old woman who presented with small bowel obstruction secondary to impaction of biliary calculi at terminal ileum with underlying cholecystoduodenal fistula (CDF). Enterolithotomy with stone extraction (ES) was performed, followed by subtotal reconstituting cholecystectomy due to iatrogenic gallbladder perforation. The diagnosis of GSI is ascertained by the presence of the Rigler’s triad on abdominal X-ray, while CDF was demonstrated by post-surgery CT images. Bile leak post-operation was managed conservatively based on the SNAP (Sepsis, Nutrition, Anatomy, Plan) approach, and spontaneous closure of CDF was observed. In a nutshell, GSI should always be kept in mind as a differential diagnosis of mechanical bowel obstruction, especially among elderly female patients. Radiological findings of Rigler’s triad aid clinical diagnosis of GSI. Despite its rare incidence, early diagnosis is crucial as it is readily treatable with surgery. ES alone is the gold standard in the management of GSI.