Pawan Mathur

Spontaneous mesenteric hematoma complicating an exacerbation of Crohn's disease: report of a case

Case PresentationSpontaneous mesenteric haematoma is a rare condition that occurs due to localized bleeding in the mesenteric vascular tree of a bowel segment in the absence of an identifiable cause. Here we report a case of spontaneous mesenteric haematoma during an inflammatory exacerbation of Crohn’s disease. The patient underwent surgical management for small bowel obstruction secondary to Crohn’s disease, however the concurrent presence of a spontaneous mesenteric haematoma in the mid-jejunal mesentery was successfully managed conservatively.ConclusionThis case identifies the first association of spontaneous mesenteric haematoma with an exacerbation of Crohn’s disease and highlights the need to consider rare differential diagnoses such as SMH when performing radiological assessment of unexplained symptoms in inflammatory bowel disease patients.

What Are the Recommendations to Ensure a Successful Multidisciplinary Team in Rectal Cancer

Multidisciplinary team-working aims to ensure all patients achieve prompt access to expert advice, up-to-date treatment and holistic care from relevant professionals with specialist knowledge and skills. This is particularly relevant in rectal cancer, where preoperative radiotherapy and chemoradiation are often delivered according to clinical findings and clinical staging (particularly in terms of the MRI). There are also many different surgical options available with varying levels of radicality and implications for future function and quality of life (QOL).

Response to Parnaby et al. (Defunctioning stomas in patients with locally advanced rectal cancer prior to preoperative chemoradiotherapy)

We read with interest the authors’ article on the double-spouted loop ileostomy. During the early part of our own departmental audit [1], inferior retraction and skin excoriation in loop ileostomies were identified as problematic, and this complication was all but completely removed by the technique of everting the distal limb. It was so successful that we included a description of the technique [2] with associated picture, (methods section, p. 485) in a single centre, prospective randomized trial. The incidence of ileostomy retraction in general [1] and in loop ileostomies in particular [2] compares favourably with the subsequent national audit [3]. While the danger of everting the wrong limb of a trephine loop ileostomy is prevented by this technique, the blind approach described by the authors is hazardous and should not be advocated, as witnessed by their two high output stomas. With a modest degree of head down tilt in most cases, it is straightforward to identify, under direct vision through the trephine, the distal 5 cm of the terminal ileum, using the ileal fat pad as the constant anatomical landmark. Only where small bowel adhesions prevent this identification, does a more valued judgement need to be made with regard to a ‘blind approach’, laparoscopy or converting to a minilaparotomy.