Foreign body ingestion is an infrequent cause of small bowel obstruction and, rarely, perforation. It is a common occurrence among pediatric patients, mentally impaired and the edentulous elderly population majority of which will pass through the gastrointestinal tract uneventfully. The likelihood of complications such as perforation, bleeding or fistula formation increases markedly particularly for sharp, stiff, and elongated objects (i.e. toothpicks, meat bones, pins, and razor blades). Diagnosis can be difficult as frequently patients are incognizant of the nature and time of ingestion. Imaging is commonly non-specific as well. We present an unusual case of a 65-year-old male who had an ileal perforation secondary to a coconut leaf midrib skewer initially presenting as small bowel obstruction. Intraoperatively, adhesions were seen in the ileum with note of the foreign body perforating two bowel loops that was not identified in preoperative imaging. This case highlights the importance of considering atypical causes of small bowel obstruction even in the background of previous surgery. Finally, early recognition, accurate diagnosis, and timely intervention are essential to improve patient outcomes and decrease mortality in such cases.

This report presents an unforeseen event involving the detachment of the gallbladder without any traumatic cause, which was incidentally detected during a scheduled laparoscopic cholecystectomy procedure. The incidence of total congenital gallbladder detachment from the liver is quite uncommon. The primary difficulty encountered in patients afflicted with this particular medical issue pertains to the intraoperative identification and localization of the gallbladder. The significance of this case report lies in its presentation of a groundbreaking finding that has the potential to provide challenges for surgeons doing laparoscopic cholecystectomy, a commonly performed surgical procedure.

Introduction Acute Appendicitis (AA) is the most common surgical emergency. Despite the use of various diagnostic parameters, the rate of negative appendectomy remains high (30%). Thus, through our retrospective study, we aim to analyse whether white blood cell (WBC) count or C-reactive protein (CRP) level is more indicative in the confirmation of AA. We also analysed imaging modalities ultrasonography (USG) and computed tomography (CT) of the abdomen to find out which is better for diagnosing AA. Methods Patients with suspected AA admitted for laparoscopic appendectomy in Saqr Hospital, Ras Al Khaimah, United Arab Emirates, during 2019-2020 were included in the study. Patients who had either or both WBC and CRP values were included in the study and their diagnosis was confirmed based on histological appendectomy findings. Data analysis was done using IBM SPSS Statistics for Windows, Version 23.0 (Released 2015; IBM Corp., Armonk, New York, United States), receiver operating characteristic (ROC) curve, and chi-square test as required. p-value of <0.05 was considered statistically significant. Results Out of the 320 patients with suspected AA, WBC had a p-value of 0.8 (insignificant). A total of 228 patients who had elevated WBC had confirmed histological diagnosis of AA, and 152 patients who were tested for CRP and had elevated levels had confirmed histological diagnosis of AA. CRP had a p-value of 0.04 (significant). However, when the ROC curve was used as evidence to see which was a better test, WBC and CRP both had a low area under the curve (AUC), which proved that they were not the most accurate diagnostic marker in diagnosing AA. However, CRP was slightly better than WBC. A total of 266 patients underwent USG abdomen and it had a p-value of 0.4 (insignificant), while 118 patients underwent CT scan, which had a p-value of 0.01 (significant). CT abdomen was statistically proven as a better radiological investigation. Also, when the ROC curve was used to compare USG and CT abdomen, CT again proved to be a better radio diagnostic method for AA. Conclusions From our study, it can be concluded that CRP is better than WBC in ruling in appendicitis and CT abdomen is better than USG in diagnosing appendicitis, but CT abdomen is only next to histological diagnosis in confirming AA. Hence, we recommend doing CRP as the primary laboratory marker for suspected cases of AA. CT abdomen is the ideal imaging modality in cases of suspected AA where clinical examination, laboratory values, and ultrasound examination are inconclusive.

Diverticular disease is a common surgical condition, especially in the Western world. Its existence is well known in Asian countries as well; however, its impact on Asian health care is not the same as that in Western countries. Diverticular disease has a variable presentation, and its implications can be challenging to manage both for the patient and the medical professionals. Diet and lifestyle are commonly associated with its etiology. In Western countries, much attention is given to diverticular disease, and with the acceptance of colonoscopy as a surveillance investigation, a greater number of people are diagnosed with diverticular disease at an early stage and overall. In acute presentations, a CT scan of the abdomen remains the investigation of choice. The most common presentation of diverticular disease is pain in the abdomen or a change in bowel habits. In most cases, diverticular disease is treated with medical intervention; however, in cases associated with severe complications or advanced stages, surgical modality remains the primary treatment.

Background Abdominal radiography is one of the most routinely performed radiological investigations in hospitals. It is one of the initial investigations done in hospitals. Numerous studies have shown that abdominal X-rays have low sensitivity in several conditions such as acute abdominal pain. Methodology This study aims to first identify whether the Royal College of Radiology guidelines are being adhered to while requesting abdominal X-rays and, second, to identify the number of unnecessary requests made in the Betsi Cadwaladr health board. This is a retrospective audit of abdominal X-ray request data collected between the 1st and 23rd of August 2022. Data were collected from the electronic radiology record system. iRefer guidelines by the Royal College of Radiology were used as a reference to compare the requests made, and data were then analysed accordingly. Data are reported descriptively using percentages. Data analysis was done using SPSS version 20 (IBM Corp., Armonk, NY, USA). Results Of the total 242 abdominal X-rays noted, 89.67% of requests were according to the iRefer guidelines while 10.33% of requests were not. A total of 73.14% of cases were suspected to have an intestinal obstruction, and the positivity rate for the same was only 12.39%. Conclusions The majority of the requests followed the guidelines. However, there is an urgent need to develop local guidelines to reduce needless abdominal X-rays.

Bucket-handle mesenteric tears remain a diagnostic challenge for clinicians. We aim to review the literature, including a single-surgeon series, to better understand their presentation and management. Three electronic databases (Ovid Medline, Embase, and PubMed) were searched for original research articles, describing relevant cases, from database inception to October 2021 using the following Medical Subject Heading (MeSH) terms: mesenteric avulsion, mesenteric tear, and blunt abdominal trauma. A retrospective review of cases managed under a single surgeon at our unit was also performed. Data extracted included demographics, mechanism of injury, presenting features, diagnostic imaging, surgical management, and patient outcome. In total, 19 studies were identified, including 22 patients (median age 34.5 years). The most common cause of injury was seat-belted road traffic accidents (77.3%), and patients commonly presented with abdominal pain (72.7%), tenderness (50%), positive seat-belt sign (54.5%), and haemodynamic compromise (45.5%). Computerised tomography scanning was the main imaging modality (68%), and the most common findings reported were abdominal free fluid (36.4%) and abdominal wall hernia (27.3%). The majority of patients were operated on within 24 hours of injury (68%), had a median length of stay of 14.5 days, and experienced an uncomplicated recovery (68%). There was no association between the development of complications and delayed surgical intervention >24 hours (p = 0.145). Our institution\'s experience was similar, with 50% of patients undergoing surgical intervention within 24 hours. The median age was 32.5 years (50% female), and the median length of stay was 11 days. A high index of suspicion, serial monitoring, including blood tests, and imaging, with a low threshold for early repeat imaging, can provide a useful guide for identifying patients with bucket-handle tears.

Background Acute appendicitis can occur at any age but is rare among people of extreme age; it is more common in teenagers and young adults. Traditionally diagnosis is made on clinical grounds. In recent times imaging techniques have been deployed to improve diagnosis and reduce negative appendicectomy rates. The aim of the study was to describe the common clinical features of acute appendicitis among our patients, highlight the role of medical imaging, and compare all these with the histological report of the excised appendix. Methods A 24-months retrospective review of all patients who underwent appendicectomy (July 1, 2019-June 30, 2021) for suspected acute appendicitis was performed. Medical records numbers of patients who had appendicectomies were retrieved from the operating room register. These numbers were used to access the hospital\'s electronic medical records database for the patients\' records. These records were reviewed for biodata, clinical features, laboratory, medical imaging findings, and histological reports. Result In this hospital, 354 appendicectomies were performed. Only 336 had complete data set suitable for further review. There were more males (N=257; 76.5%) than females (N=79, 23.5%), yielding a male to female ratio of 4:1. There were also more Saudi citizens (n=266, 79.2%), with the predominant age group being 11-30 years. Abdominal pain was the predominant symptom (100%) and was localized to the right iliac region in 331 (98.7%) of patients. Other symptoms recorded were anorexia (n=247, 73.5%), vomiting (n=190, 56.5%), and nausea (n=93, 27.7%). Atypical symptoms included diarrhoea (n=27, 8%) and constipation (n=12, 3.6%). Acute appendicitis, complicated appendicitis, and no appendicitis were the reported histological disposition in 174 (51.8%), 124 (36.9%), and 38 (11.3%) cases respectively. Abdominal CT scan had a higher sensitivity (98.6% vs 70.5%), higher diagnostic odd ratio (2.5 vs 1.4) and a lower miss (false negative) rate (1.4% vs 29.5%) compared to ultrasonography. However, the CT scan, from this study, has a rather low specificity (3.4%) and high false positive rates (96.5%). Open (n=205; 61%) and laparoscopic (n=131;39%) approaches were used for the appendicectomies. In our study, 44 patients were diagnosed with the decision to operate based on clinical grounds; and of this, 42 (95.4%; n=44) had confirmatory histology reports of appendicitis. Also, 38 patients had negative appendicectomy; giving a negative appendicectomy rate of 11.3%. This high rate may be due to the lower specificity and high false positive rate observed in this study. The post-operative complication rate was 21.4%, and this was solely due to surgical site infection, and this was more common with the open approach (p=0.001). Conclusion Suspected acute appendicitis was the sole indication for our appendicectomies. A computerized tomography scan was a more reliable diagnostic tool than ultrasonography. Despite the fact that acute appendicitis is majorly a clinical diagnosis, and good clinical acumen is an excellent skill in the management of patients, we observed an overreliance on medical imaging for diagnosis. Open appendicectomies were more common, and surgical site infection was the sole complication of surgery. There was a relatively high negative appendicectomy rate for an image-assisted diagnosis.

Unhealthy nutritional habits and the current western lifestyle have led to an increased incidence of acute diverticulitis, which mainly affects older patients. However, the disease course in younger patients might be more severe. It has a continued increase in surgical practice, as it is the most common clinical condition encountered in the emergencies. Diagnosis and management have changed over the past decade. C-reactive protein > 170 mg/L represents the cut-off point between moderate and severe diverticulitis, and a CT scan is mandatory. It demands urgent surgical management and has high morbidity and mortality rate, especially in immunosuppressed patients, reaching up to 25%. According to the contemporary guidelines, there have been certain indications for conservative management and re-evaluation (administration of antibiotics, CT-guided drainage of the abscess, when it is > 4 cm). They include pericolic air bubbles or a small amount of fluid, absence of abscess within a distance of 5 cm from the affected bowel or abscess ≤4 cm. In other cases, Hartmann\'s sigmoidectomy is the procedure of choice. An alternative choice, nowadays, is resection and primary anastomosis with or without diverting stoma, especially in younger patients. Laparoscopic lavage only versus primary resection has been performed in severe cases of Hinchey III or IV. Damage control surgery, possible open abdomen, and reoperation are recommended in severe sepsis. Hinchey\'s classification may not be absolutely adequate, and several modifications have been proposed. Current classification criteria (CRP, qSOFA score) are more appropriate. The decision-making must be individualized depending on the hemodynamic status (septic shock), age, comorbidity, immune status, intraoperative findings, and MPI (Mannheim peritonitis index).

Hyperthyroidism primarily presents with the symptoms and signs of thyrotoxicosis. However, many cases might present with a precipitating factor that unmasks the hyperthyroid status of the patients. These factors are associated with a stress condition, with infections being the most common factors, diabetic ketoacidosis, acute coronary syndrome, and pulmonary embolism. We present a case of hyperthyroidism masqueraded as acalculous cholecystitis.

Necrotizing fasciitis is a highly invasive disease characterized by rapidly worsening inflammation of the fascia associated with necrosis of the subcutaneous tissue. It is a rare, life-threatening disease and needs early diagnosis through acute clinical awareness. It warrants urgent and aggressive surgical management. We report a rare and fatal case of spontaneous necrotizing soft tissue infection (NSTI) of the anterior abdominal wall caused by Finegoldia magna in a chronic diabetic patient. The initial presentation and radiological features suggested a pelvic abscess. Other acute abdomen differentials were also considered, and the patient underwent an exploratory laparotomy where a necrotic anterior abdominal wall with copious purulent secretions was noted. The organism Finegoldia magna was identified from the necrotic tissue sample with other cultures coming back negative. The risk posed by NSTIs is very high, and hence though the incidence is low, clinicians should be aware of the potential dangers of this disease to avoid delays in initiating appropriate treatment.