A concealed small bowel perforation in an adult secondary to bicycle handlebar trauma.

Traumatic abdominal wall hernia (TAWH) secondary to bicycle handlebar is a rare injury. The majority of the literature describes abdominal wall herniation in children. We present a rare case of TAWH in an adult with a concealed small bowel perforation. Although clinical examination in conjunction with computed tomography can exclude the majority of solid organ injuries, small bowel injuries can often be missed. Our case initially revealed a serosal tear in the small bowel but, on close inspection, a separate 3mm perforation was identified, hidden in the small bowel mesentery. We strongly support a low threshold for operative intervention if there is any suspicion. Moreover, we stress the importance of meticulous examination during laparotomy as this injury could have been easily missed, resulting in potential morbidity or mortality in a patient sustaining such an injury.

Do patients assess rectal bleeding accurately?

BACKGROUND: The accuracy of a patient's assessment of the volume of blood passed per rectum is unknown. The aim of the present study was to compare subjective estimations with known amounts of blood. METHODS: Thirty subjects (10 patients, 10 nurses and 10 doctors) made a visual estimation of four volumes of blood (0.25 mL, 10 mL, 50 mL, 200 mL), each placed in a standardized way into a toilet bowl. Subjects gave their estimations in mL, and also by drawing a line on a cup at the level to which they estimated that the amount of blood would fill the cup. Statistical analysis was carried out using Student's t-test. Multiple comparisons were analysed by anova. RESULTS: There was no significant difference between the groups in their estimations of each of the four volumes. Each group made a statistically significant overestimation for the 0.25 mL, 10 mL and 50 mL volumes with cup marking, as well as with estimation in mL (except for patients with the 50 mL volume, where there was a non-significant overestimation). For the 200 mL volume, patients and doctors made statistically significant underestimations with cup marking, but for nurses the underestimation did not reach significance. For the 200 mL volume estimations in mL, both nurses and doctors made underestimations that were not significant. CONCLUSIONS: Small to moderate amounts of blood in the toilet bowl are subjectively significantly overestimated, whereas larger volumes tend to be underestimated. This may have implications for the management of patients presenting with rectal bleeding.

Oral sodium phosphate solution is a superior colonoscopy preparation to polyethylene glycol with bisacodyl.

PURPOSE: The aim of this study was to compare the efficacy and patient tolerance of two bowel preparations for colonoscopy. METHODS: Three hundred twenty-three consecutive patients undergoing colonoscopy were randomly assigned to receive either oral sodium phosphate, or 2 liters of polyethylene glycol solution preceded by the stimulant laxative bisacodyl. Patients were asked to record the effects of the preparation, noting any vomiting, nausea, or abdominal pain, and to determine a discomfort rating on a scale of 1 to 5. One hundred sixty-nine patients were assigned to the oral sodium phosphate solution, and 154 to polyethylene glycol with bisacodyl. Surgeons were blinded to the preparation used and rated the quality of the bowel preparation on a scale of 1 to 5. RESULTS: Ninety-nine percent of patients in the sodium phosphate group drank all of the solution as opposed to 91 percent of patients in the polyethylene glycol with bisacodyl group. Patients in the sodium phosphate group reported significantly less discomfort (P = 0.002). No significant difference was reported for vomiting, nausea, or abdominal pain associated with the preparations. The quality of bowel cleansing was considered by the colonoscopists significantly better for the sodium phosphate group than the polyethylene glycol with bisacodyl group (P < 0.000001). CONCLUSIONS: Colonoscopy preparation with sodium phosphate solution is better tolerated and more effective than polyethylene glycol with bisacodyl.

Posterior tibial tendon rupture in a world class runner.

Complete rupture of the posterior tibial tendon occurs infrequently. It can be caused by a variety of factors, including repeated steroid injections, chronic tenosynovitis, and decreased blood supply to the tendon. The authors report a world class runner who sustained a rupture requiring surgical intervention.