HighlightsEndometriosis causing acute large bowel obstruction is extremely rare.Diagnostic challenges still remain in recognising intestinal endometriosis with or without intestinal obstruction.Definitive surgical management is needed for endometriosis causing acute intestinal obstruction.

Tension pneumoperitoneum is commonly caused by gastrointestinal perforation and pulmonary causes are extremely rare. We present a case of a 47-year-old male post motor vehicle accident with a suspected left-sided haemopneumothorax on initial chest x-ray. CT of the chest post chest tube insertion showed a left-sided diaphragmatic rupture and an extensive diaphragmatic hernia. While en-route to the operating theatre, the intubated patient developed tension pneumoperitoneum with positive pressure ventilation and required immediate surgical intervention and repair. A review of the literature around tension pneumoperitoneum and diaphragmatic hernia in trauma is discussed.

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. ABSTRACTParastomal pyoderma gangrenosum is a rare condition where classical skin lesions are found around or near abdominal stomas. Literature reports a 2-4.3% prevalence of parastomal pyoderma gangrenosum in patients with inflammatory bowel disease who undergo stoma surgery. This debilitating skin condition is often missed or wrongly treated due to lack of awareness and understanding. We present a 51-year-old female with parastomal pyoderma gangrenosum on a background of Crohn's disease. Current literature of diagnosis and management is also discussed.(This page in not part of the published article.)

Introduction: There has been an increasing body of literature on conservative management of acute appendicitis recently. The aim of this study was to evaluate the current practice of non-operative management of acute appendicitis in Eastern Health, a Melbourne metropolitan health network Acute appendicitis is the most common cause of acute abdominal pain leading to hospital admission and surgery. About 20% of the cases are complicated with perforation, peritonitis or collection while majority is uncomplicated [1]. The first appendicectomy for acute appendicitis was performed by McBurney in 1889 [2]. In patients with complicated appendicitis, the preferred management is largely conservative as there is strong evidence to suggest operative management during acute admission leads to higher rates of morbidity and mortality [3][4][5][6]. Appendicectomy has been the preferred option in treatment of acute uncomplicated appendicitis since the 19th century. It is well tolerated by majority of the patients with a high cure rate however complications including serious intra-abdominal organ injuries still exist [7,8]. The emergence, and increased use of laparoscopy was associated increased numbers of surgical intervention with high negative appendicectomy rates and unnecessary surgery related complications [7][8][9]. In the past two decades, there has been an increasing body of literature evaluating the validity of antibiotics treatment alone in managing acute uncomplicated appendicitis and results are promising [10][11][12][13][14][15][16][17][18]. With this shifting trend in management of acute appendicitis we aim to review the performance in management of acute appendicitis in our health network in the past five years, focusing on the cohort of patients managed conservatively, the management decisions and follow up results.

Congenital midgut malrotation predisposing to small bowel volvulus around left-sided feeding jejunostomy A 44-year-old female with severe gastroparesis was presented 4 weeks following laparoscopic insertion of a feeding jejunostomy tube sited in the left abdomen. Her symptoms included intermittent abdominal pain, bloating, vomiting and weight loss. On examination, she appeared dehydrated and cachectic. Her abdominal findings were remarkable for epigastric tenderness and distension. Nasogastric decompression was promptly administered together with intravenous hydration, electrolyte replacement and parenteral nutrition.An abdominal computed tomography (CT) scan demonstrated small bowel obstruction with dilated stomach and duodenum proximal to the feeding jejunostomy site (Fig. 1a). A vascular swirl and a 360 rotation of the jejunostomy tubing were also seen (Fig. 1b). Notably, her duodenum did not cross the midline (Fig. 1c), and her superior mesenteric artery (SMA) was positioned right of the superior mesenteric vein (SMV) (Fig. 1d). These findings were consistent with a small bowel volvulus around her jejunostomy tube in the setting of congenital mid-gut malrotation. Fig 1. Computed tomography demonstrating (a) distended stomach (st) and duodenum (duo), (b) small bowel volvulus around the jejunostomy site, (c) right-sided duodenojejunal flexure and (d) reversed superior mesenteric artery (SMA) and vein (SMV) anatomy.