This 70 year-old man presented to the accident and emergency room having fallen down a
flight of stairs. He complained of shortness of breath and left sided pleuritic chest pain. Clinical he had
surgical emphysema. This chest x-ray was taken. It confirms the presence of surgical emphysema and the
lower rib fractures. He was admitted for analgesia and chest physiotherapy. He made an uncomplicated
recovery from his injuries.
This 80 year-old man was admitted with sudden onset of right sided abdominal
pain. He was on prophylactic warfarin because of atrial fibrillation. Abdominal examination showed a
mass on the right side of his abdomen. He had extensive abdominal wall bruising. His INR was
6.0. A contrast-enhanced abdominal CT was undertaken. This showed an extensive right-sided
retroperitoneal haematoma with anterior displacement of the right kidney. His anticoagulation was reversed
with fresh frozen plasma. He made a slow, but uncomplicated recovery from his injury.
This 40 year old lady underwent a routine laparoscopic cholecystectomy. No
on-table cholangiogram was performed. On the second post-operative day she became jaundice. The
biochemical picture was one of obstructive jaundice. An urgent percutaneous cholangiogram was
arranged. This showed dilatation of both hepatic ducts. Two clips were seen lying across the proximal common
bile duct. This bile duct injury was unrecognised at the time of the initial surgery. A hepatico-jejunostomy
was performed. This resolved her jaundice but she continues to suffer from intermittent right upper
This frail 85 year-old lady presented with a 6 month history of rectal bleeding and a
change in bowel habit, particularly increasing constipation. A barium enema showed the presence of
'apple-core' stricture in the proximal sigmoid colon. The diagnosis of colonic carcinoma was confirmed by
biopsies taken at flexible sigmoidoscopy. An abdominal ultrasound showed the presence of liver metastases.
She was considered unfit for an anterior resection. In view of her symptoms of intestinal obstruction, it
was decided to insert a colonic stent. This was placed under radiological guidance. It improved her
symptoms for three months before she eventually died.