282 Cholecystoappendicular Fistula- 1st Ever Reported Case

A 30-year-old male presented with a history of recurrent episodes of acute cholecystitis; first acute attack associated with fever and nausea was 18 months prior to this presentation, for which he was managed conservatively for acute cholecystitis with antibiotics and analgesia following an ultrasound that showed features of acute cholecystitis with no obvious gallstones.

The patient had further episodes of acute cholecystitis with no signs of obstructive jaundice and subsequent ultrasound showed multiple small gallstones. Due to the severity of his symptoms, he was scheduled for a planned cholecystectomy.

During surgery (right subcostal incision)- findings were that of a contracted gall bladder with dense adhesions, after careful dissection a fistulous tract between the appendix and gallbladder was identified along with a cholecystoduodenal fistula.

An en-bloc cholecystectomy plus appendicectomy was performed with the duodenotomy repaired. On the first day post op there was approximately 300 ml of bilious effluent in drain, a white cell count-8.1 x 109 and hemoglobin -12.1 g/dL, Serum bilirubin-1.4mg/dL, ALP-104mg/dL. The second and third post-operative days were uneventful with minimal bile mixed serous fluid in drain respectively with no other complains, following which the drains were removed and patient discharged home.

Biliary-enteric fistulae have been found in 0.9% of patients undergoing biliary tract surgery. The most common site of communication of the fistula is a cholecystoduodenal (70%), followed by cholecystocolic (10–20%), and the least common is the cholecystogastric fistula accounting for the remainder of cases.

No case of cholecystoappendicular fistula has been reported so far.

719 Colovaginal Fistula from Neglected Vaginal Pessary; Fallouts from the COVID-19 Pandemic

An 86-year-old lady was admitted with a one-week history of feeling unwell, polyuria, dysuria, urinary and faecal incontinence. She had previously been treated for recurrent UTIs by her GP. On examination she had suprapubic tenderness but no peritonism. Observations revealed tachycardia of 122bpm with a temperature of 36.3*C. Inflammatory markers were raised with a white cell count of 22.0x106 /L and CRP 129 mg/L. Urine cultures grew Pseudomonas aeruginosa. She was managed for urosepsis with intravenous antibiotics.

Past medical history included vaginal pessary for uterine prolapse, congestive cardiac failure, hypertension, polymyalgia and osteoporosis She lived alone with no package of care.

On admission she improved with intravenous antibiotics however she had a perineal examination due to ongoing faecal and urinary incontinence and was noticed to be passing faeces per vaginam. A colo-vaginal fistula was suspected, and she was reviewed by the gynaecologist who noted her pessary had been in-situ for up to a year and her routine appointment to have it changed was cancelled due to the COVID-19 pandemic.

An MRI Pelvic scan confirmed a 3x2cm rectovaginal fistula.

She was reviewed by the general surgery team and the decision was made for her to be defunctioned to prevent her episodes of recurrent UTIs and improve her quality of life. She successfully had a laparoscopic end colostomy with an uneventful post-operative period.

This case highlights the harms caused from the cancellation of appointments and demonstrates a rare cause of rectovaginal fistula.

78 A Lockdown Dilemma; Ingestion of Magnetic Beads Presenting as Right Iliac Fossa Pain and Sub-Acute Small Bowel Obstruction

A 13-year-old girl presented with a three-day history of migratory right iliac fossa pain. Observations and inflammatory markers were normal, and an ultrasound scan was inconclusive. A provisional diagnosis of non-specific abdominal pain or early appendicitis was made, and she was discharged with safety netting advice.

She represented six days later with ongoing abdominal pain now associated with multiple episodes of vomiting; hence, the decision was made to proceed to diagnostic laparoscopy rather than a magnetic resonance scan for further assessment as recommended by the radiology department.

Intra-operative findings revealed 200mls of serous fluid in the pelvis, normal-looking appendix, dilated stomach, and a tangle of small bowel loops. Blunt and careful dissection revealed fistulous tracts that magnetized the laparoscopic instruments.

A mini-laparotomy was performed with the extraction of fourteen magnetic beads and the repair of nine enterotomies.

Foreign body ingestion is a known cause of abdominal pain, which in some cases might mimic or even be the cause of acute appendicitis.

This case highlights the importance of careful history taking in children presenting with acute abdominal pain of doubtful aetiology.