Post-menopausal acquired diaphragmatic herniation in the context of endometriosis

Introduction: Acquired diaphragmatic hernias are most commonly associated with traumatic thoracic injury and rarely heal spontaneously. Conditions that promote peritoneal seeding, such as endometriosis, are associated with spontaneous acquired diaphragmatic hernia formation. Non-traumatic acquired diaphragmatic herniation has previously been described in the context of catamenial pneumothorax, however post-menopausal endometriotic diaphragmatic herniation has not been previously reported. Presentation of case: A 57 year old post-menopausal female presented with a strangulated ischaemic loop of small bowel herniating through an acquired right sided endometriotic diaphragmatic hernia not previously visualised on imaging. Clamshell thoracolaparotomy was conducted and the necrotic section of small bowel was resected. The diaphragm was repaired and the patient recovered post-operatively without complications. Discussion: This patient had a complete intestinal malrotation presenting acutely with a small bowel obstruction and herniation through an acquired diaphragmatic rupture. This was possibly related to a diaphragmatic defect caused by endometriosis. Conclusion: We presented a case of a post-menopausal acquired diaphragmatic herniation secondary to endometriosis; resulting in acute intestinal obstruction and bowel infarction. To our knowledge, such a case has not been previously reported in existing literature

A two-decade diagnostic dilemma of a post-cholecystectomy syndrome presenting with a remnant cystic stump stone causing Mirizzi syndrome

[Extract] A 62-year-old female diagnostic dilemma has multiple presentations for over 2 years with sharp stabbing epigastric and right hypochondrial pain radiating posteriorly on the background of an open cholecystectomy for a gangrenous gallbladder in 1997. The pain was self-resolving over days with only pain relief, otherwise there was a scarcity of symptoms (Table S1). Her past medical history (Table S1), multiple normal serum lipases, and an initial Computerized Tomography (CT) completed in 2018 did not identify the cause of the pain. Physicians were consulted and excluded cardiac and respiratory as causes of pain. Two gastroscopies with biopsies over the two-year period only showed lactose intolerance and mild gastritis, but medication and dietary changes did not prevent further episodes of pain. Presenting 2 years after the initial attack with identical pain associated with subjective fevers, dark urine, and pale stool lead to a repeated CT scan followed by a magnetic resonance cholangiopancreatography (MRCP). A large 14 mm stone was found only on the MRCP in the proximal remnant cystic duct with surrounding inflammation suggesting chronic stumpitis, (Fig. 1). The associated swelling lead to dilatation and obstruction of the upstream hepatic ducts (Figs. 1-3) reflected in the deranged bilirubin and liver function test results, Table S2. Despite multiple ERCPs and application of the SpyGlass system, the stone was not retrieved until a laparoscopic cholecystectomy was performed to remove the stone via an in incision on the remnant gallbladder pouch with subsequent complete resolution of pain and symptoms to date

Acute variceal haemorrhage in the context of posterior flail chest

[Extract] Flail chest occurs in 5–13% of patients with chest wall injury and is associated with higher rates of pulmonary contusion compared with other types of chest wall trauma.1 Patients with multiple rib fractures are susceptible to intrathoracic, intra‐abdominal, upper extremity and head injuries. Up to 81%2 of patients with multiple rib fractures can develop haemothorax, which is usually evident on initial presentation