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A 48-year-old non-smoking man underwent laparotomy for peritonitis immediately after taking ibuprofen 800 mg 6 hourly for 14 days for back pain. His only other medication was long-term omeprazole 20 mg per day. At operation he had three separate perforations in his proximal jejunum. Fifteen centimetres of jejunum were resected with primary anastomosis. Histology showed focal mucosal ischaemic changes with normal mucosa between. There was no vasculitis. The perforations were attributed to ibuprofen intake. He made an uneventful recovery and was instructed to refrain from non-steroidal anti-inflammatory drug (NSAID) intake. He was readmitted …

Non-steroidal anti-inflammatory drugs (NSAIDs) can produce diaphragm disease where multiple strictures develop in the small bowel. This typically presents with anaemia and symptoms of small bowel obstruction. The strictures develop as a result of circumferential mucosal ulceration with subsequent contraction of rings of scar tissue. We report a case of a 47-year-old woman with a 6-month history of NSAIDs abuse who presented with subacute small bowel obstruction 1 year after stopping NSAIDs. CT and MRI showed multiple ileal strictures with florid locoregional lymphadenopathy. A malignant diagnosis such as lymphoma was considered likely as florid mesenteric lymphadenopathy has not been previously reported in diaphragm disease. Laparotomy with small bowel resection was therefore performed. Histology showed diaphragm disease with the enlarged mesenteric nodes having reactive features. Gross locoregional lymphadenopathy should not deter a diagnosis of diaphragm disease in cases of multiple small bowel strictures where there is a strong history of NSAIDs use.

The finding of unusual contents within hernias merits publication so as to raise surgeons’ awareness of the structures that could be encountered during hernia repair.1 ,2 We describe a case of a 66-year-old man who underwent elective transabdominal preperitoneal bilateral inguinal hernia repair. At laparoscopy, a large cystic structure was seen arising from the pelvis (figure 1). The hernias were repaired and the patient was informed of the abdominal finding before being discharged home later the …

A 35-year-old man was admitted following daily vomiting for 2 weeks. He reported bouts of unexplained vomiting over the preceding 10 years. Gastroscopy showed obstruction in the second part of the duodenum with normal mucosa on biopsy (figure 1). CT demonstrated dilation of the first part of the duodenum caused by narrowing of the second part (figure 2). There was no pancreatic mass. At laparotomy, a ring of pancreatic tissue was found encircling the second part of the duodenum causing obstruction (figure 3). This is …

Using feeding catheters to maintain gut function and optimise nutrition is commonplace. We highlight the pitfall of inadequate monitoring of catheters when used in stomas. A 44-year-old woman initially presented with intestinal obstruction; at laparotomy she underwent a 25 cm proximal jejunal resection, with the creation of a jejunostomy and mucous fistula. Postoperatively nutrition optimisation became paramount. Initially feeding was wholly parenteral. Progressively enteral nutrition was initiated, yet due to the difficulty with tolerance and fistula output; a 22F catheter was placed in …

We describe two cases of recurrent major umbilical bleeding in male patients with Childs A liver cirrhosis and portal hypertension. Both patients had umbilical hernias with omentum incarcerated in the hernial sac. In both cases, portosystemic abdominopelvic CT scan had shown omental varices without significant paraumbilical cutaneous varices. Previous reports have shown that venous communication can develop between omental varices and overlying abdominal wall scars, resulting in spontaneous cutaneous bleeding. We concluded that there was a similar mechanism for the umbilical bleeding in our cases and both were successfully treated by excising the umbilicus, ligating the omental varices within the hernia sac, returning the omentum to the abdominal cavity and repairing the hernia defect. This cause for umbilical bleeding has not been previously reported. We advise that with similar cases, excision of the umbilicus and ligation of the omental varices is safe and effective treatment. Umbilical bleeding is a well recognised but rare complication of portal hypertension. In previously reported cases, it has arisen from rupture of umbilical varices that have developed due to portosystemic communication between the recanalised umbilical vein and the periumbilical veins of the abdominal wall.1–8 We present two cases of recurrent major umbilical bleeding from omental varices incarcerated within an umbilical hernia. Both cases were treated successfully with excision of the umbilicus and ligation of the omental varices. This is the first report of umbilical bleeding from omental varices in patients with umbilical hernias and portal hypertension. We wished to raise awareness of this potentially life-threatening condition and have discussed its pathogenesis, investigation and surgical management. ### Case 1 A 51-year-old man presented with spontaneous bleeding from his umbilicus. He described blood pouring out of his umbilicus as if a tap had been turned on (figure 1). His clothes had become soaked with blood. He had Childs A …