Sudden Respiratory Failure after a Coughing Paroxysm.

We report a case of an 85-year-old female, previously demented and dependent on others, who presented to the emergency department with sudden dyspnea following a coughing paroxysm. She was polypneic and with a diminished vesicular murmur at pulmonary auscultation but with audible bowel sounds in the right hemithorax. Arterial blood gases showed hypoxemic respiratory failure but the additional blood work was unremarkable. A thoracic radiograph suggested the presence of small bowel on the thoracic cavity. A thoracic computed tomography confirmed the diagnosis of an anterior right giant paracardiac transdiaphragmatic hernia of small bowel through the foramen of Morgagni with secondary passive pulmonary atelectasis. A posterior left transhiatal gastric hernia was also found. She was treated conservatively with nasogastric intubation and discharged home two days later, asymptomatic and without respiratory failure. Spontaneous diaphragmatic hernias are extremely rare, non-traumatic surgical emergencies, almost invariably requiring surgical correction. This case shows that a conservative approach is an alternative in selected patients.

Giant granadilla's seeds phytobezoar rectal impactation: a very unusual case of intestinal obstruction.

A 78-year-old Caucasian man presented to the emergency department with bloody diarrhoea, diffuse abdominal pain and fever with 1-week duration. He had just returned from Angola where he had been treated for a presumed Clostridium difficile infection without improvement. He had no relevant medical or familiar history except for hypertension and prostate benign hyperplasia. He was drowsy, feverish and eupnoeic. His oxygen saturation on pulse oximetry was 92%, blood pressure was 173/99 mm Hg and pulse rate 100 beats per minute. Except for a distended, silent and painful abdomen, particularly on lower quadrants, the rest of the examination was unremarkable. A CT showed a mesh-like mass inside the rectum conditioning colonic obstruction and distention. This turned to be a giant granadilla's seeds phytobezoar and was removed endoscopically. Five days later, the patient had a colonic perforation requiring total colectomy. He made a full recovery after rehabilitation for 3 months.