Spontaneous multiple jejunal perforations are rare. In India, the commonest cause of small bowel perforation is typhoid fever followed by tuberculosis. We report a case of multiple jejunal and ileal perforations in a 23-year-old young woman who was known to have ulcerative colitis on medical therapy including steroids. She was then diagnosed to have active pulmonary tuberculosis and commenced on anti-tuberculosis therapy. She presented with generalised peritonitis and underwent emergency bowel resection with proximal enterostomy and creation of mucous fistula of the distal ileum. Post-operative course was stormy due to sepsis and she eventually succumbed on the 3rd post-operative day. Histopathological examination revealed non-specific changes and was not contributory to diagnosis. Possible causes of spontaneous jejunal perforations are discussed and the literature is reviewed. This case, despite a fatal outcome, is being reported to highlight the need for high index of suspicion in such situations.

We report a case of a 56-year-old woman who presented with clinical features suggestive of acute pancreatitis. She had a similar episode 5 years ago. A blood pressure (BP) recording of 80/50 mmHg in the presence of acute pancreatitis led to the diagnosis of circulatory shock and vasopressors were about to be commenced. However, her overall appearance was stable and measurement of BP in the lower limbs was normal. An angiogram revealed left subclavian artery stenosis which explained the low BP reading on left arm. The patient responded to conservative management of pancreatitis, however refused further evaluation of subclavian stenosis. This case is being reported to highlight a clinical dilemma and a clinical lesson. Dilemma arises if the pancreatitis and subclavian artery stenosis is just a coincidental occurrence or it is a case of IgG4 related disease consisting of autoimmune pancreatitis (AIP) type 1 with subclavian artery stenosis a part of extra-pancreatic manifestation of the IgG4 related disease spectrum. This distinction is important in management of pancreatitis and other organ involvement. It is important to examine a patient fully and especially the vascular system - wherein all pulses are to be felt and blood pressure recorded in both sides and both limbs - whenever there is a conflict between the condition/appearance of the patient and the signs that we elicit. In this case recognising that BP was normal in the lower limbs prevented unnecessary use of vasopressors.