Improving outcome following life-threatening gastrointestinal bleeding not amenable to endoscopy in an ASA grade 5 patient: lessons learned.

We present a 74-year-old woman, who developed massive haematemesis and hypovolaemic shock. Her management was challenging, as the bleeding site could not be identified during oesophagogastroduodenoscopy, she was not fit for a general anaesthesia and not able to lie flat due to heart failure, caused by pericardial effusion. She underwent an emergency laparotomy and gastrotomy under a combined thoracic epidural and lumbar spinal regional anaesthesia in a sitting position, 45° to horizontal plane. The bleeding site was identified as a Dieulafoy lesion on the posterior wall of the stomach and was controlled by under running the lesion. She had an uneventful recovery and is symptom-free post-surgery for a year at present.

Traumatic splenectomy in a cirrhotic patient with hepatitis C and alcoholic liver disease.

Non-operative management is the management of choice for haemodynamically stable patients with blunt splenic injury. However, coexistent liver cirrhosis poses significant challenges as it leads to portal hypertension and coagulopathy. A 52-year-old man sustained blunt abdominal trauma causing low-grade splenic injury. However, he was found to have liver cirrhosis causing haemodynamic instability requiring emergency laparotomy. His portal hypertension led to severe bleeding only controlled by aortic pressure and subsequent splenectomy. Mortality from emergency surgery in cirrhotic patients is extremely high. Despite aggressive resuscitation, they may soon become haemodynamically unstable. Therefore, traumatic splenectomy may be inevitable in such patients with portal hypertension and splenomegaly secondary to liver cirrhosis even in low-grade injury.

Krukenberg tumour arising from adenocarcinoma of the gastro-oesophageal junction in a 28-year-old female presenting as lower abdominal swelling mimicking an inguinal hernia.

Krukenberg tumours arising from gastro-oesophageal adenocarcinomas prior to the fourth decade are extremely rare. The authors present the case of a 28-year-old patient who was then 4 years of age, residing close to the Chernobyl nuclear reactor at the time of the nuclear disaster in 1986, and was found to have late-stage Krukenberg tumours from a gastro-oesophageal primary. Her presentation with right groin pain initially raised a suspicion of an occult groin hernia. Clinicians are reminded to delve deeply into the social history in their enquiries with Eastern European patients who present with unusual clinical features and were in utero, young and living in proximity to the nuclear fallout zone at the time of the incident.