We report the case of a rare cause of bowel obstruction in a 12-year-old girl who presented with a short history of abdominal distension and vomiting after a month of unexplained urinary frequency and weight loss. Abdominal radiographs demonstrated small bowel obstruction with an unknown pelvic mass. A raised CA125 suggested a possible ovarian lesion and a magnetic resonance scan was interpreted as supportive of this pathology. Intra-operatively a 120x90x70mm cystic mass was found attached to the caecal serosa, immediately adjacent to the ileocaecal valve. There was an associated 180-degree twist of the terminal ileum and ascending colon. A limited right hemicolectomy was performed, and histopathology confirmed the diagnosis of a caecal intestinal duplication cyst. Post-operatively she has recovered well, with resolution of her obstructive and urinary symptoms. Given the unusual age of presentation, uncommon location of the cyst and the diagnostic challenges incurred, the authors wish to share their experience of managing an atypical duplication cyst.

Aim Acute appendicitis is the most common surgical condition in children in the UK. We did a Quality Improvement Project to determine if our hospital's paediatric appendicitis antibiotic guidelines were being followed. Method Data was collected retrospectively for all patients admitted with acute appendicitis between 01/05/2021 and 14/09/2021 at a tertiary paediatric centre. The compliance to centre protocol for antibiotic administration was assessed, including cefuroxime dose per kilogram. Following educational intervention, a second cycle of prospective data collection was performed 29/09/2021 to 18/11/2021 to reassess compliance and close the loop. Results Initial data collection (n=34) showed protocol compliance at 57.6%; where compliance was correct dose, duration, and combination of antibiotics. Notably, we showed 4 patients developed collections despite being on triple antibiotic therapy. Of these 3 were on the lower dose 20mg/kg Cefuroxime regime despite intraoperative findings. Following a Departmental meeting, the protocol standard dose of Cefuroxime was changed to 50mg/kg (max 1.5 grams as per BNF) for all presentations of acute appendicitis. Results were then fed back to the team and changes implemented; including updating the previous flowchart posters found in A&E, theatres, and ward. Second round of data collection (n=12) showed 91.7% compliance with protocol. Of the patients in this time, none developed abdominal collections. Conclusions This quality improvement project shows significant improvements in outcomes of appendicectomy, as well as improvements in protocol compliance achieved with education and simple interventions. We have shown an increase in compliance