Lime and lithiasis: a case of choledocholithiasis complicated by limy bile.

Limy bile syndrome (LBS) is a condition in which the biliary tract is filled with radiodense calcium carbonate rich sludge. This rare condition can complicate the management of commonly encountered biliary conditions such as choledocholithiasis. We present a case of a male in his fifties who presented to hospital with a 12-day history of abdominal pain, nausea and jaundice. Imaging and laboratory findings demonstrated a dependent radio-dense substance within the biliary system as well as an obstructing calculus at the duodenal ampulla. Management with endoscopic retrograde cholangiopancreatography alone was insufficient and further surgical management was required. With no clear published guidelines on LBS and associated cholelithiasis, management is variable. We present this case as an addition to the literature on the management of choledocholithiasis complicated by LBS.

Idiopathic spontaneous intraperitoneal haemorrhage: A near fatal presentation of acute abdomen requiring prompt diagnosis.

INTRODUCTION AND IMPORTANCE: Idiopathic spontaneous intraperitoneal haemorrhage is a rare and life-threatening condition that results from non-traumatic visceral artery rupture in the latter half of pregnancy and within the postpartum period [1-3]. CASE PRESENTATION: A 32 -year-old woman presented to emergency department, 14 weeks post-partum, with sharp left sided abdominal pain, nausea, and vomiting. Initial computed tomography (CT) was suggestive of non-specific colitis from transverse to descending colon of unclear cause. Six hours into admission she became haemodynamically unstable with abdominal peritonism resulting in emergency laparotomy. Intra-operative findings showed large volume haemoperitoneum with an active bleed from the middle colic artery. CLINICAL DISCUSSION: Symptoms and clinical presentation of Idiopathic spontaneous intraperitoneal haemorrhage is variable and ranges from vague abdominal pain to haemorrhagic shock. A latent period of several hours may be followed by a rapid progression of symptoms owing to rapidity of extravasation[3]. Pathogenesis has been suggested to arise from the increased physiologic demands during the intrapartum period, wherein repeated distension of vessels and increased tortuosity leads to a predisposition for rupture [4]. CONCLUSION: Diagnosis of Idiopathic spontaneous intraperitoneal haemorrhage is difficult but should be a differential in those who are post-partum presenting with abdominal pain. Patients should be assessed with CT angiography and treatment focused around aggressive resuscitation, surgical exploration, and ligation [3].

Managing surgical waiting lists through dynamic priority scoring.

Prioritising elective surgery patients under the Australian three-category system is inherently subjective due to variability in clinician decision making and the potential for extraneous factors to influence category assignment. As a result, waiting time inequities can exist which may lead to adverse health outcomes and increased morbidity, especially for patients deemed to be low priority. This study investigated the use of a dynamic priority scoring (DPS) system to rank elective surgery patients more equitably, based on a combination of waiting time and clinical factors. Such a system enables patients to progress on the waiting list in a more objective and transparent manner, at a rate relative to their clinical need. Simulation results comparing the two systems indicate that the DPS system has potential to assist in managing waiting lists by standardising waiting times relative to urgency category, in addition to improving waiting time consistency for patients of similar clinical need. In clinical practice, this system is likely to reduce subjectivity, increase transparency, and improve overall efficiency of waiting list management by providing an objective metric to prioritise patients. Such a system is also likely to increase public trust and confidence in the systems used to manage waiting lists.

The Duari hernia and recognition of the femoral vein compression sign.

Femoral hernias can be difficult to diagnose and are at high risk of strangulation. This report is of a rare case of an irreducible femoral hernia containing caecum and appendix presenting as an emergency. To the authors' knowledge, there have only been three cases reported, the first described by Duari. This case was incorrectly diagnosed preoperatively as an inguinal hernia, so the CT diagnosis of femoral hernias is reviewed, in particular demonstrating the radiological use of the femoral vein compression sign.