Pseudoaneurysm of the cystic artery is a rarely described cause of haemobilia. We report the unusual presentation of upper gastrointestinal haemorrhage due to a pseudoaneurysm of the cystic artery secondary to acute cholecystitis that was complicated by gallbladder perforation and liver abscess in an 88-year-old male. The original CT scan had demonstrated a high density focus in the gallbladder neck that was thought to represent a calculus. Selective embolization of the cystic artery resulted in cessation of the haemorrhage. Owing to the patient’s frailty and comorbidities, he was not considered suitable for cholecystectomy. The case emphasizes the need for a high level of awareness of pseudoaneurysmal disease in association with inflammatory conditions.

Ann R Coll Surg Engl 2010; 92: 697-699 697Patients admitted as an emergency with abdominal pain often undergo two standard imaging studies in the acute setting, namely an erect chest and supine abdominal radiograph. The indications for the erect chest radiograph (CXR) are first to exclude free gas under the diaphragm as a result of a perforated viscus, and second to attempt to exclude an intrathoracic condition as a cause for the abdominal symptoms.The Royal College of Radiologists (RCR) recommends a CXR be performed when there is a suspected visceral perforation, to exclude air under the diaphragm. This does not supersede a thorough clinical examination and should not be done routinely for patients with abdominal pain. 1Although the cost of a CXR is relatively small at approximately £20 per film, the fact that acute abdominal pain accounts for 50% of all emergency surgical admissions 2 means that the overall costs for this investigation are significant. Furthermore, although the radiation exposure of a CXR is low at 0.2 mGy, 3 all unnecessary radiation should be avoided. In addition, from a clinical perspective, requesting investigations which are unlikely to be of any benefit in obtaining the diagnosis simply delays the commencement of treatment.The aim of this study was to address this issue by examining both the quantity and quality of requests made for emergency chest radiographs in patient presenting with abdominal symptoms. It has been suggested that changes to the training schemes of junior doctors and the increased pressure on emergency departments to manage their patients within a limited time might increase the number of unnecessary investigations performed on emergency admission patients. This, in turn, may lead to an increased number of investigations with normal results. In this study we try to analyse the role of the chest X-ray (CXR) as a diagnostic tool in patients presenting with acute abdominal pain. PATIENTS AND METHODS A retrospective study was performed of the request forms and results of all chest radiography performed on patients admitted on the emergency surgical intake with acute abdominal pain through utilisation of the prospectively maintained electronic radiology database. The indications were compared to the guidelines published by the Royal College of Radiologists (RCR) which have been adopted as the standard of care. RESULTS A total of 334 chest X-rays were identified of which only 23 (7%) had new findings. Four (1%) patients had free gas under the diaphragm. Of the CXRs, 258 (77%) were reported normal whilst 53 (16%) had old changes which were described in their hospital records and previous radiographs. Of the CXRs with new findings, only 20 were clinically significant and, of these, four (1%) were surgically significant. CONCLUSIONS The majority of CXRs performed on emergency surgical admissions with abdominal pain are unnecessary. By obtaining a clear history, performing a thorough clinical examination and following the RCR guidelines most of the CXRs could be avoided. This wo...

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MRI is a useful and sensitive tool to investigate occult femoral neck fracture. Inpatient MRI waiting times can significantly be reduced by a targeted approach which embodies improved team working.