This 65 year-old lady presented with a 2 week history of jaundice, pale
stools and dark urine. Abdominal examination was unremarkable. Her urine contained conjugated
bilirubin. Her liver function tests showed an obstructive picture. Abdominal ultrasound showed a
dilated common bile duct. She proceeded to this investigation - an ERCP. It shows two large stones
within the bile duct. An attempt to extract them with a balloon catheter and Dormia basket failed.
Mechanical lithotripsy was also unsuccessful. She proceeded to an open cholecystectomy and exploration of
her bile duct. A T-tube cholangiogram showed no retained stones. ERCP is the 'gold standard'
investigation for the detection of bile duct stones. It is not without complications and has a
complication rate of 5% and mortality of about 1%.
This 85 year-old man presented with a 5 day history of absolute constipation
and abdominal distension. For 3 months he had noted irregularity in bowel habit but no tenesmus. His
abdomen was distended. Rectal and sigmoidoscopic examination were normal. This plain abdominal x-ray
shows distended small and large bowel down to the level of the sigmoid colon. A water-soluble contrast
enema identified an obstructing carcinoma of the proximal sigmoid colon. After resuscitation the patient
proceeded to a laparotomy. A mobile tumour was noted and a Hartmann's procedure was performed.
Histology showed a Duke's C adenocarcinoma.
This 70 year-old lady presented with sudden onset of severe epigastric
pain. She was toxic, dehydrated and unwell. She had marked abdominal peritonism. Her serum
amylase was increased. Her prognostic criteria suggested severe pancreatitis. She was managed on a
high dependency unit. This contrast enhanced CT was performed. It show gross oedema and failure of
enhancement of much of the body and tail of the pancreas.