A 72-year-old Caucasian man was transferred from Trangie Hospital with 7 h history of generalized abdominal pain. It was associated with hypotension. There was no history of fever, vomiting, change in bowel habit or weight loss. He has history of type 2 diabetes mellitus, hypertension, atrial fibrillation (AF), obstructive sleep apnoea and ischaemic heart disease. He is on warfarin for AF. He lives with his wife in Trangie independently. He is an occasional drinker and ex-smoker.On examination, he was afebrile, blood pressure was 70 mmHg systolic and heart rate was 100/min. Abdomen was soft and palpable mass in right lower quadrant was identified. He was taken straight to computed tomography (CT) after resuscitation. CT abdomen and pelvis showed a large (>20 cm) haematoma in the right of the abdomen, with active bleeding in the region of the gastroduodenal artery (GDA). An aneurysm is seen in the superior margin of the collection (Fig. 1).His blood tests showed haemoglobin was 81, white cell count was 13.5 and international normalized ratio was 4.5. He was found to have metabolic acidosis with pH of 7.18 and lactate of 6.5. He was given 2 units each of packed red blood cells and fresh frozen plasma, Fig. 3. Cross-sectional CT showing pancreatic pseudocyst.

, respectively in both group. There was only one complication after PC (peritonitis after PC, 3.4%), who is one of two mortality cases in palliation group (22.2%). Resumption of oral intake was possible 3.2 AE 2.1 days after PC in bridge group and 3.0 AE 2.4 days in palliation group except two mortalities due to underlying diseases. We tried 12 LC and one failed due to bile duct injury (success rate was 91.6%). Mean operation time for LC was 106.8 AE 32.5 which is a little bit longer. Conclusion: PC is a good procedure for bridge procedure before elective LC and palliation of symptom in patients with acute cholecystitis and ASA classification more than 3.

A 48-year-old man presented to a regional hospital with a 48-hour (2-day) history of generalized abdominal pain. The pain was worse in the left upper quadrant (LUQ). There was associated vomiting, loose bowel motions and the patient was in acute urinary retention. The past medical history included appendicectomy, ventral hernia repair and depression. There was no history of intravenous drug use, immunosuppression, infectious disease or travel and the patient was employed as a janitor at a local school. The patient was afebrile and the remaining vital signs were within normal limits. Abdominal examination revealed LUQ tenderness only. The white cell count was 11.5 × 10 9 /L and the C-reactive protein was 65 mg/L.

No abstract

International Journal of Case Reports and Images (IJCRI) is an international, peer reviewed, monthly, open access, online journal, publishing high-quality, articles in all areas of basic medical sciences and clinical specialties.Aim of IJCRI is to encourage the publication of new information by providing a platform for reporting of unique, unusual and rare cases which enhance understanding of disease process, its diagnosis, management and clinico-pathologic correlations.IJCRI publishes Review Articles, Case Series, Case Reports, Case in Images, Clinical Images and Letters to Editor. Website: www.ijcasereportsandimages.comSmall bowel obstruction in an adult patient with situs ambiguous and mid gut malrotation Shwe Phyo Han, Jonathan Grassby ABSTRACT Introduction: Situs ambiguous or heterotaxy syndrome is defined as the abnormal positioning of internal viscera relative to the normal. Diagnosis in adult is extremely rare as 90-99% of the patients have severe cardiac abnormalities and die by the age of five years. Case Report: A 32-year-old male was presented to hospital with sudden onset abdominal pain, abdominal distension, vomiting and absolute constipation for one day. There was no other medical problems. Examination was also unremarkable. Abdomen was distended and generally tender. Per rectal examination showed empty rectum. Blood tests were unremarkable. Computed tomography scan of abdomen and pelvis showed closed loop mid to distal small bowel obstruction with small bowel wall thickening. Malrotation of the bowel was noted. It also showed that stomach and spleen were on the right side of the body. Emergency laparotomy showed small bowel volvulus and spleen, stomach, duodenojejunal flexure and small bowel were in the right side of the abdomen and colon was in the left side of the abdomen. Ileocecal valve was noted in the left side of the abdomen. Adhesiolysis and derotation of the affected small bowel were performed. Appendicectomy was performed due to its location in left lower quadrant. The patient was discharged from the hospital four days after the operation. Conclusion:There is no case report on adult situs ambiguous presented with acute intestinal obstruction before. We report this case for extremely rare occurrence of situs ambiguous with mid gut malrotation presented with small bowel obstruction in the adult age group.