Delayed Extrahepatic Biliary Leak: A Rare Presentation 9 Years Post-Laparoscopic Cholecystectomy.

BACKGROUND Biliary leaks are an important cause of the acute abdomen condition, carrying significant levels of morbidity and mortality. They are most commonly the result of acute iatrogenic or blunt trauma, with an identifiable cause. In comparison, spontaneous and delayed biliary leaks are rare phenomena occurring in the absence of recent surgery, endoscopic intervention, or trauma. Here we report the case of a 77-year-old woman presenting with acute abdominal pain, distension, and rigors caused by an extrahepatic biliary leakage 9 years after laparoscopic cholecystectomy. CASE REPORT Laparoscopic hepatobiliary intervention, rather than open surgery, is associated with increased risk of biliary tree injury, including biliary leaks, which typically arise in the immediate postoperative period. This report concerns a 77-year-old woman presenting with acute abdominal pain, distension, and rigors due to extrahepatic biliary leakage 9 years following elective laparoscopic cholecystectomy for cholelithiasis. Computed tomography (CT) showed large-volume abdominopelvic ascites with no obvious source. Intra-abdominal exploration revealed a large biloma with 2 lacerations in the gallbladder fossa. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) found only a vague leak in the extrahepatic biliary tree, with no focal defect or retained biliary calculi. Intra-abdominal drainage and common bile duct (CBD) stenting were performed. Repeat ERCP undertaken 3 months later, however, identified a calculus within the CBD. CONCLUSIONS The patient's rare presentation of biliary leakage 9 years after cholecystectomy raises the question of whether the condition was delayed or spontaneous in nature. The biliary calculus identified 3 months following the leakage raises the possibility of retained biliary calculi.

Intermittent neck swelling: an unusual presentation of achalasia cardia.

Achalasia is a rare cause of neck swelling. We report the case of a 75-year-old woman, who presented with an intermittent, unilateral neck swelling, associated with dysphagia, weight loss and regurgitation. The patient underwent a gastroscopy and barium swallow. This confirmed a dilated oesophagus with poor motility and hold up of liquid and food residue above the gastro-oesophageal junction, thus revealing the swelling was secondary to severe achalasia. The patient was managed with botulinum toxin injections and pneumatic dilatations but the results were short lived. She is now having manometry and is being considered for a Heller myotomy or peroral oesophageal myotomy. Delayed diagnosis and treatment of achalasia can result in the development of a neck swelling, which could later cause airway compromise and subsequent mortality. Achalasia should therefore be considered in patients with an initial diagnosis of gastro-oesophageal reflux disease who do not respond to proton pump inhibitors.

Intra-abdominal rectal perforation post-haemorrhoidal artery ligation operation and converted Ligasure open haemorrhoidectomy.

We report an unfortunate case of rectal perforation and subsequent peritonitis in a 74-year-old lady who underwent haemorrhoidal artery ligation in order to treat complex large external and internal haemorrhoids. Serious complications following haemorrhoid surgery are rare and this is the first documented case of delayed intra-abdominal rectal perforation following a haemorrhoid artery ligation operation and converted Ligasure open haemorrhoidectomy.

Paralytic Ileus Secondary to Methamphetamine Abuse: A Rare Case.

Methamphetamine hydrochloride, colloquially referred to as "crystal meth," is a potent psychoactive amphetamine derivate. Methamphetamine produces stimulant effects in the user including increased energy and alertness as well as inducing intense euphoric symptoms and suppressing appetite through its dopaminergic, serotonergic, and adrenergic actions. Use of methamphetamine can adversely affect cardiovascular, neurological, and gastrointestinal physiology leading to significant morbidity. We present a rare case of paralytic ileus secondary to methamphetamine abuse which has only once before been described in the literature.