Gallstone ileus with an enterovaginal fistula: a rare complication of pelvic radiotherapy.

Gallstone ileus is a rare cause of small bowel obstruction. Chronic gallstone irritation can lead to the formation of a cholecystoduodenal fistula, with gallstone impaction typically in the terminal ileum. Rarely gallstones can become impacted in other structures such as the colon or can even erode through the bowel. We present an unusual case of a gallstone ileus which resulted in the formation of an enterovaginal fistula, secondary to previous pelvic radiotherapy. Our case highlights the importance of considering fistula formation as a late complication of radiotherapy and how this can alter expected features of other pathologies, such as a gallstone ileus.

Prostate cancer and sarcoma: Challenges of synchronous malignancies.

Synchronous primary malignancies are a rare finding which can be difficult to diagnose. We present the case of a 57-year-old patient with a high prostate specific antigen who was found to have prostate cancer on subsequent magnetic resonance imaging. A skeletal metastasis was also identified at the time, although no osteoblastic activity or sclerosis was identified on skeletal scintigraphy or computed tomography, respectively. The patient was started on hormonal therapy and follow-up imaging revealed the prostate cancer to have reduced in volume. Despite this, the skeletal metastasis appeared unchanged on magnetic resonance imaging and an F18-choline positron emission tomography study was negative. A computed tomography guided bone biopsy was organized and this demonstrated metastatic leiomyosarcoma. As a result, an F18-fluorodeoxyglucose positron emission tomography study was performed to find the primary lesion which demonstrated a large malignant tumor within the calf. Subsequently, the patient was referred to a tertiary sarcoma unit. This case highlights the challenges involved in diagnosing and managing synchronous malignancies.

A case of a chronic salmonella infection following Roux-en-Y gastric bypass surgery, treated successfully by a laparoscopic cholecystectomy.

We report a case of chronic infection caused by Salmonella and cured by a laparoscopic cholecystectomy after Roux-en-Y gastric bypass (RYGB) surgery for obesity. This patient presented with a 2-year history of chronic abdominal pain, loose stools and excessive weight loss. Her stool and urine cultures were positive for Salmonella Despite multiple courses of antibiotics, she remained positive.After undergoing a laparoscopic cholecystectomy, the patient became asymptomatic and stools remained negative. In chronic carriers for Salmonella, the gall bladder is the common reservoir for the bacteria and removing it is usually curative.The possibility that the source of the may be in the biliary limb of her bariatric procedure and not in the gall bladder remained a concern.In patients who have had a RYGB, cholecystectomy is an effective treatment.All patients presenting with abdominal symptoms following RYGB should have stool and urine cultures taken as part of their work up.

Port site endometrioma: a rare cause of abdominal wall pain following laparoscopic surgery.

Endometriomas are a rare cause of abdominal wall pain. We report a case of a port site endometrioma presenting with an umbilical swelling. The patient underwent a laparoscopy for pelvic endometriosis 6 months previously and presented with a swelling around her umbilical port site scar associated with cyclical pain during menses. Ultrasound scan reported a well-defined lesion in the umbilicus and MRI scanning excluded other pathology. As she was symptomatic, she underwent an exploration of the scar and excision of the endometrioma with resolution of her symptoms. Precautions should be taken to reduce the risk of endometrial seeding during laparoscopic surgery. All tissues should be removed in an appropriate retrieval bag and the pneumoperitoneum should be deflated completely before removing ports to reduce the chimney effect of tissue being forced through the port site. The diagnosis should be considered in all women of reproductive age presenting with a painful port site scar.

A case of endometriosis presenting as an inguinal hernia.

Endometriosis is a common clinical presentation for gynaecologists. Occasionally it can present to general surgeons as a swelling in the groin or abdominal wall. This condition should be included in the differential diagnosis in female patients. A 32-year-old woman with a 2-year history of a painful persistent lump in her right groin was referred to the general surgeons by her general practitioner. She was referred with a diagnosis of a suspected inguinal hernia. MRI excluded a hernia and exploration of the groin and subsequent histology confirmed the lesion to be an endometrial deposit.