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Length-of-stay is an important quality measure for emergency departments. The study aimed to find predictors for prolonged LOS in children. A cross sectional study was conducted from Jan 2017 to Mar 2018. Data were extracted from medical records of 5609 pediatric patients admitted to the King Abdullah Bin Abdulaziz University Hospital-ED, Riyadh, Saudi Arabia. Median LOS of the children was 74 mins. Multivariable analysis showed the difference in the expected LOS between patients DAMA and their non-DAMA counterparts was 72 mins. Difference in the expected LOS between patients at emergent and non-urgent triage was 89 mins, between urgent and non-urgent triage was 51 mins and difference between less urgent and non-urgent triage was 16 mins. Future studies should explore the contributing managerial and clinical factors that can explain such associations and might be the focus for future policy changes to reduce LOS in ED pediatric settings in Saudi Arabia.

This study aimed to design of electronic curriculum for educational evaluation in the light of Quality Matters standards and measuring effectiveness in develop electronic evaluation skills for (42) students female from students of education college in King Saud University and it's an experimental study group apply to them :(Cognitive test for electronic evaluation skills for educational evaluation curriculum and three card for notice skills sides for electronic evaluation skills). After proceed the statistical treatments, the study results showed the following: There is a statistically function difference at the level (α >01) between the average scores of the study sample in after and before application for the collective test for cognitive side foe electronic evaluation skills for educational evaluation curriculum for education college students in King Saud University for the benefit of before application scores average. There is a statistically function difference at the level (α >01) between the average scores of the study sample in after and before application for all main skills and total score for performance side notice cards (Electronic tests, Electronic questionnaire, Electronic achievement file) for electronic evaluation skills for educational evaluation curriculum for education college students in King Saud University for the benefit of before application scores average. Suggested design efficiency for educational evaluation curriculum in the light of Quality Matters standards for education college students in King Saud University in electronic evaluation skills development. Recommendations: Design education college curriculum in the light of Quality Matters standards. Training faculty members on design electronic curriculums in the light of Quality Matters standards. Interesting in electronic evaluation skills development for students' teachers in all education colleges. Benefit from the curriculum to training teachers during the service on electronic evaluation skills. Suggestions: Study the attitudes of faculty members and students about the suggested curriculum and barrier of it's application. Design an educational environment in the light of Quality Matters standards to develop electronic evaluation skills for secondary school level teachers.

Introduction Numerous preoperative scoring systems predict difficult laparoscopic cholecystectomy. Recently, the intraoperative difficulties which are facing surgeons are studied. A new scoring system categorize patients according to many intraoperative findings with a final outcome whether converting to open cholecystectomy or continuing laparoscopically. Patients and methods This prospective study included 120 patients admitted for laparoscopic cholecystectomy for symptomatic gallstones from October 2019 to August 2020. Intraoperative difficulties were evaluated and patients were categorized according to intraoperative scoring for cholecystitis severity and compared depending to the rate of conversion to the open technique. Results Most patient were middle aged females having multiple gallstones, the mean operation time was 35 min and 7.8% of patients were converted to open cholecystectomy because of intraoperative difficulty. There was a significant correlation between the conversion rate and each of distended and/or contracted gall bladder, inability to grasp the gall bladder with traumatic forceps, stone ≥1 cm impacted in Hartman's pouch, and bile or pus outside gallbladder (P values: 0.002, 0.000, 0.008 and 0.015) respectively, and no significant correlation with gallbladder adhesions, adhesions from previous upper abdominal surgery, BMI>30, and Time to identify cystic artery and duct >90 min (P values: 0.123, 1, 1, 0.078) respectively. Conclusion New intraoperative scoring systems are valuable in predicting difficulties and preventing increase operation time and possible injuries. The main points of difficulties are distended or contracted gallbladder, large stone impaction, difficult grasping the wall of the gall bladder and the presence of bile or pus outside the gall bladder., Highlights • Laparoscopic cholecystectomy is a safe procedure with some difficulties. • The definition of difficult LC is not well established until now. • Recently intraoperative difficulties facing the surgeons are studied. • Inflammation, adhesions, and obesity are some factors for difficulty.

Introduction Many clinical and pre-clinical studies suggested the protective effect of vitamin D against cancer development and cancer progression. Vitamin D deficiency is highly prevalent worldwide, and its link to DNA damage is worthy to study. It has been shown that vitamin D supplementation can reduce the risk of cancer with a favorable prognosis. Studies on DNA damage in different types of cancer and its link to plasma vitamin D has not been found in literature. Patients and methods In this study we included 45 patients with different types of cancers and 35 healthy individuals as controls. The plasma vitamin D levels were measured in all participants. DNA damage levels of peripheral blood (mononuclear) cells in 45 newly diagnosed and untreated cancer patients and in 35 healthy individuals were measured using Alkaline Comet Assay technique. Results The DNA damage observed in cancer patients was significantly higher than in healthy individuals. Interestingly, we have found a significant inverse correlation between the plasma levels of vitamin D and DNA damage in cancer patients (p, Highlights • Vitamin D deficiency is highly prevalent worldwide, and its link to DNA damage is worthy to study. • Transformation of normal tissue to neoplasms are the result of molecular changes in genetic materials. • Deficiency of vitamin D probably one of the risk factors of cancer.

Aim. This study aimed to retrospectively compare the survival outcomes over two years between teeth with proximal dental caries that were restored with stainless-steel crowns to those that were pulpotomized and then restored with a stainless-steel crown in patients who were rehabilitated under general anesthesia. Participants and Methods. The records of 131 patients aged between two to six years who had stainless-steel crowns placed under general anesthesia and had two-year follow-up were screened. 340 teeth with moderate proximal caries on the radiograph (D2) were included in the study. Of these, 164 teeth were treated with a pulpotomy and stainless-steel crown, while 176 teeth were crowned without a pulpotomy. The type of each tooth was compared using the Chi-squared test and Kaplan–Meier survival analysis, and curves were plotted based on the two-year outcomes. Results. Treatment: the sample comprised 59 males (mean age 4.73 years, SD ± 1.4 years) and 72 females (mean age 5.2 years, SD ± 2.0 years). The Kaplan–Meier regression model showed no significant difference in survival outcomes between teeth that had been pulpotomized and those that had not ( p = 0.283). Conclusion. Within the limitations of the current study, we can conclude that performing a pulpotomy does not influence the survival outcome of mild/moderate proximal caries restored with stainless-steel crowns under general anesthesia.

BACKGROUND: Self-expanding metal stents (SEMS) are used as a bridge to surgery for colon cancer patients as an alternative to emergency surgery. Currently, there is a paucity of literature from Saudi Arabia on the preoperative usage of SEMS. OBJECTIVE: Determine whether SEMS are associated with a higher rate of complications. DESIGN: Retrospective cohort study SETTINGS: Tertiary care hospital in Saudi Arabia. PATIENTS AND METHODS: In patients diagnosed with obstructing colon cancer, up-front surgical resection was compared with insertion of SEMS followed by surgical resection between the years 2009 and 2013. MAIN OUTCOME MEASURES: Rate of stent-related short-term complications. Secondary endpoint, postoperative complications. SAMPLE SIZE: 65. RESULTS: Twenty-four (36.9%) patients underwent SEMS placement; 41 (63.1%) underwent primary surgery. The median (interquartile range) hospital stay was significantly higher among the SEMS group (13 [8.5] days versus 7 [3] days in the primary surgery group, P CONCLUSION: SEMS is associated with longer hospital stays and short-term serious complications. Further research should be conducted, preferably with a larger sample size. LIMITATIONS: Retrospective design, small sample size. CONFLICT OF INTEREST: None.

Colorectal cancers are among the commonest causes of cancer related morbidity and mortality worldwide. Adenomatous polyps which develop dysplastic changes are the main cause of invasive cancer. P53 inactivation is a key genetic step in the occurrence of cancer. The degree of the formation of the blood vessels inside the tumor (microvessel density) increases the ability of the tumor to have local infiltration, metastatic potential and may reflect the tumor metabolic activity. A total number of 104 patients who underwent surgeries for colorectal adenocarcinoma followed for 5 years. Patients were categorized into 4 categories based on tumor expression of P53 and micro-vessel density, 64.42% of patients were females, 58.7% died from colorectal cancer during the 5-year period, 37.5% had 5-years survival free from cancer, and 16.3% survived with recurrence, 28.8% had over expression of both P53 and MVD. A significant correlation was found between: P53 and MVD with the site of tumor occurrence being more significant with left-sided colonic tumors, the clinical stage being more significant with stage III disease, and with the survival rate being more significant in patients who died during this period, P values 0.025, 0.01, and 0.001 respectively. Overexpression of P53 and MVD are associated with higher mortality and more advanced disease. We advise a more aggressive form of therapy for colorectal adenocarcinomas expressing high level of both factors and tumors with high expression of both factors may need modification in the chemotherapeutic drugs or radiation therapy with closer follow up than tumors having lower expression., Highlights • Colorectal cancers are among the commonest causes of cancer related morbidity and mortality worldwide. • P53 inactivation is a key genetic step in the occurrence of cancer. • Microvessel density is the degree of the formation of the blood vessels inside the tumor. • Microvessel density increases the tumor ability of local infiltration, metastatic potential and metabolic activity.

Obesity and its related comorbidities is a major health problem worldwide. Sleeve gastrectomy is regarded to be one of the most effective bariatric surgeries with a relatively low risks of complications. Gastrobronchial fistula is an extremely rare and a serious complication after bariatric surgeries, it is associated with major morbidity. A 48-year-old obese lady with a BMI of 40 had underwent laparoscopic sleeve gastrectomy 7 years ago, she developed leak at the 10th postoperative day which was treated with drainage. After 4 years she presented with left subphrenic abscess which was treated with drainage, splenectomy and endoscopic stent. After one year she had repeated chest infections and was coughing-up recently ingested food items. CT-scan showed left subphrenic collection with abnormal fistulous tract between the bronchial tree and the subphrenic cavity. Left thoracotomy was performed, a complex fistula was found between the remnant parts of the gastric fundus, transverse colon and lung. Resection of the fistula was performed, the stomach and colon were closed in 2 layers, resection of the affected segment of lung was performed and the diaphragm was sutured. The BMI was 19 at the last admission. Gastro-colo-bronchial fistula is unreported after sleeve gastrectomy and the management is challenging. Surgeons may follow the same principles of management as in cases of gastrobronchial fistula, but we suggest earlier surgical intervention with the administration of broad spectrum antibiotics. Nutritional deficiencies must be corrected, and such patients must be treated with multidisciplinary team, with an extended duration of follow-up., Highlights • Sleeve gastrectomy is one of the most effective bariatric surgeries with a relatively low complication rates. • Gastro-colo-bronchial fistula is unreported after sleeve gastrectomy and the management is challenging. • Multidisciplinary team is required for the management of such patients.

Introduction The thyroid gland has a very important role in hematopoiesis, blood disorders are frequently seen in patients with thyroid disorders. Thyroid hormones have direct effect on blood parameters by stimulating erythrocytes precursors and indirectly by enhancing erythropoietin production. Patients and methods This is a case-control study which included 300 subjects who were grouped to 3 equal groups as a control, hypothyroidism, and hyperthyroidism groups. Patients with inherited or acquired red cell abnormalities, those receiving treatment for thyroid disorder or anemia, patient with chronic diseases, aged, Highlights • The thyroid gland has a very important role in hematopoiesis. • Females are more affected by thyroid disorders than males. • Thyroid hormones directly stimulate erythrocytes precursors and indirectly by enhancing erythropoietin production.

Highlights • Foreign bodies may be ingested unconsciously, intentionally or in patients who have psychological abnormalities. • The majority of foreign bodies are passed smoothly with no problems. • Ingestion of sharp and long foreign bodies usually requires surgical intervention., Background Foreign bodies may be ingested unconsciously, intentionally or in patients who have psychological abnormalities. The majority of foreign bodies are passed smoothly with no problems if they passed the esophagus, however some may be lodged in areas of anatomical narrowing which may require endoscopic or surgical intervention. Case presentation A 37-year -old mentally abnormal woman presented to the emergency department complaining from abdominal pain for 2 days. The family reported a history of ingestion of multiple metallic nails one week before presentation. Abdominal examination showed generalized tenderness and guarding. Plain abdominal X-ray showed multiple metallic nails in the upper abdomen and the right lower abdomen. Laparotomy was performed, one of the nails was causing perforation of the gastric wall, huge number of metallic nails were extracted from the stomach and cecum, appendectomy was performed. Conclusion Ingestion of sharp and long foreign bodies usually requires surgical intervention, after surgery close observation and psychological consultation is required to prevent repeated ingestions.

Introduction. Meckel’s diverticulum is the commonest congenital anomaly of the gastrointestinal tract in humans that is commonly encountered during surgical practice as the cause of the patient’s presentation or as an incidental finding during other unrelated procedures. Most clinical symptoms are caused due to its complications. Results. The mean age of the involved patients was 24.79 years with slight male predominance, 62.9% males compared to 37.1% females. The mean length of the diverticulum was 55.21 cm. The most common emergency presentation was right lower quadrant abdominal pain in 31% of the patients, intestinal obstruction in 28.6%, acute lower abdominal pain and guarding and acute abdomen in 18.6% and 15.7% of patients, respectively, bleeding per rectum in 2.9%, acute right upper quadrant abdominal pain in 1.4%, and obstructed paraumbilical hernia containing the diverticulum in one patient. Perforation of the Meckel’s diverticulum was reported in 18.6%. Histopathological examination showed acute inflammation in the wall of the diverticulum in 37.1%, lymphoid hyperplasia in 24.3%, hemorrhagic necrosis in 22.9%, and chronic inflammation in 8.6%. Ectopic mucosa was detected in 50% of the cases, gastric mucosa was detected in 42.86%, ectopic pancreatic mucosa was detected in 5.71%, and both gastric and pancreatic types in 1.43%. Conclusion. Long diverticula are more liable to develop complications. At surgery, inspection and palpation of the wall of the diverticulum must be done for any evidence of inflammation, necrosis, perforation, or abnormal thickening of the walls of the diverticulum. Resection of the segment of the bowel that contains the diverticulum with primary anastomosis is preferable to other procedures due to the risk of leaving behind an abnormal heterotopic mucosa.

Background: Alopecia areata (AA) is a common, non-scarring type of hair loss, affecting approximately 2.1% of the population. Many modalities of treatment are recommended like steroid injection, topical Immunotherapy, and several systemic therapies, but none of them can prevent or alter the course of the disease with variable degrees of improvement.Objective: To evaluate efficacy and safety of superficial cryotherapy versus intralesional corticosteroid injection in the treatment of alopecia areata. Patients and Methods: Thirty patients aged 14-58 years, with localized multiple patchy alopecia areata (at least two patches), were enrolled in this study. In each patient, one patch was treated by superficial cryotherapy via liquid nitrogen spray. This involved two treatment cycles/sessions, each lasting 3-5 seconds. The other patch was treated with intralesional steroid injection (triamcinolone acetonide 5 mg/ml, 0.1ml /cm2. Sessions were repeated every three weeks up to three months. The target lesions were evaluated clinically using SALT score and by 2 blinded dermatologists and dermoscopically at baseline, every session, and the end of the study (one month after the last session). Results: At the end of the study, the clinical response (number of the patients with hair growth > 20%) to superficial cryotherapy was about 83.3% (25 patients out of 30 patients). While in the steroid group the clinical response was about 80% (24 patients out of 30 patients). There was a statistically significant reduction in SALT score and dermoscopic parameters at the end of the study in both groups with no significant difference between them. There was a significant clinico-dermoscopic relation between hair regrowth and dermoscopic findings.Conclusion: Superficial cryotherapy is an effective and safe therapeutic modality for AA with advantages of simplicity and noninvasiveness.

Significance Tirzepatide is a dual agonist of the glucose-dependent insulinotropic polypeptide receptor (GIPR) and the glucagon-like peptide-1 receptor (GLP-1R), which are incretin receptors that regulate carbohydrate metabolism. This investigational agent has proven superior to selective GLP-1R agonists in clinical trials in subjects with type 2 diabetes mellitus. Intriguingly, although tirzepatide closely resembles native GIP in how it activates the GIPR, it differs markedly from GLP-1 in its activation of the GLP-1R, resulting in less agonist-induced receptor desensitization. We report how cryogenic electron microscopy and molecular dynamics simulations inform the structural basis for the unique pharmacology of tirzepatide. These studies reveal the extent to which fatty acid modification, combined with amino acid sequence, determines the mode of action of a multireceptor agonist.

Parasitic haemoprotozoan and gastrointestinal (GI) diseases are a big issue in animal husbandry and one of the most significant causes for livestock economic losses in underdeveloped countries. This study aimed to record preliminary information on the prevalence of haemoprotozoan and gastrointestinal parasites of Awassi breed of sheep imported from Syria into Sulaymaniyah province, Iraq. Faecal and blood samples were randomly collected from a total of 714 sheep of both sexes from June to September 2019. Giemsa staining technique, direct faecal smear, saturated salt flotation method, and simple sedimentation technique, were applied to diagnose the parasitic stages in the coprological and blood specimens. The overall prevalence rate was 75.63%. Single and mixed infection rates of parasites were 55.46%, and 20.16%, respectively. GI parasites and haemoprotozoan infection rates were 78.15%, and 20.16%, respectively. Of all parasites, the most prevalent was Eimeria spp. (68%), followed by Babesia spp. (20.15%), Balantidium coli (5.90%), Fasciola hepatica (2.50%), and strongyles (1.7%). The prevalence rates for GI parasites and haemoprotozoa varied considerably in regard to sex categories. It is recommended that strict quarantine procedures, adequate parasitological monitoring, and therapeutic approaches should be implemented to animals transported from bordering countries to minimize the incidence of parasite infection.

Introduction and importance Fistula is an abnormal tract communicating two epithelial surfaces, uterocutaneous fistula is an extremely rare. The classical presentation is cyclical bleeding from an abnormal opening in the scar of previous cesarean section. Case presentation A 28 year-old was presented 6 months after cesarean section with history of severe pain and blood discharge during menstruation from the previous transverse supra-pubic scar. The patient had history of previous 2 cesarean sections. Abdominal examination revealed a localized tenderness at site of previous operation scar with 1*1 cm opening at the central part of the scar which was discharging blood during pressure over the lower abdomen. There was no urine discharge from the scar. Vaginal examination by the speculum was normal. Clinical discussion Endometriosis was suspected and the patient received medical treatment with little improvement. Later, surgical intervention was done, the scar was excised with an abnormal fistulous tract connecting endometrial cavity at the site of the previous scar was found. Complete excision of the tract was done and the uterus was re-sutured using a slowly-absorbable suture material. The patient had no complications with regular cycles. Conclusion Uterocutaneous fistula is rare and usually follow cesarean section, suturing the uterus with non-absorbable suture material is reported in this case to be one of the underlying causes, other causes include infection, necrosis, foreign bodies, or malignancy. The fistula tract must be defined and any associated infection controlled, complete resection of the fistulous tract and suturing the uterus with absorbable suture material is required., Highlights • Causes of uterocutaneous fistulas are numerous like iatrogenic, endometriosis, malignancy, etc. • The classical presentation is cyclical bleeding from the scar of previous cesarean section. • A combined medical and surgical approach may be required.

Background Participation in Colorectal cancer (CRC) screening programs is low in Saudi Arabia. Public awareness of CRC and knowledge of available screening tools are crucial for improving screening uptake. This study aimed to examine the level of awareness and knowledge of CRC among the Saudi population. Materials and methods A survey-based study was conducted on 1912 residents of Riyadh, Saudi Arabia. The survey comprised 20 questions; these concerned the definition of the colon and rectum; the function of the colon; the incidence, risk factors, symptoms, screening methods, prevention methods, and treatment methods for CRC; and the value of early detection of CRC. Results Of the 1912 participants who completed the survey, only 51.7% knew that the colon was the large intestine, while 57% knew that the rectum was the end of the large intestine. Colonoscopy was the preferred screening tool (72.8%). Most respondents believed early detection of CRC through colonoscopy is associated with high survival rates. However, 65.7% of the participants reported that they would not like to undergo a CRC screening. Higher education level was also associated with knowledge that CRC can develop asymptomatically, with postgraduates most likely to know this (P = 0.032). Conclusions There is a lack of knowledge regarding CRC among certain demographic groups in Saudi Arabia, and education and screening programs should target populations with the most limited knowledge., Highlights • Colonoscopy was the preferred CRC-screening method among the sample. • The biggest barrier to CRC screening was fear of diagnosis. • Majority of respondents chose stress as stress factor for CRC.

Background: Toxoplasmosis is caused by an obligate intracellular opportunistic protozoan parasite, Toxoplasma gondii, with a worldwide distribution. T. gondii infection among pregnant women during the first trimester may transmit infection to the fetus with serious congenital consequences. No data is available on knowledge, attitude and preventive behavior towards toxoplasmosis among pregnant women in Kuwait. This cross-sectional study evaluated knowledge, attitude, and preventive behavior towards toxoplasmosis among women in Kuwait, and reviewed the situation in the Middle east.Methods: Data related to socioeconomic status, knowledge and attitude towards toxoplasmosis were collected from 326 adult female school/university students, and 86 pregnant women through a self-administered online questionnaire during 2019-2021. Participants were divided into two main groups: women with pregnancy experience (PEG) and never-pregnant group (NPG).Results: PEG (n=212) included 114 currently pregnant and 98 women with history of an earlier pregnancy. NPG included 200 subjects. All participants belonged to a medium-to-high social status and minimum high school education. Nearly 50% of PEG women had inadequate knowledge towards toxoplasma infection, and only 33 (15.6%) knew its mode of transmission compared to 35 (17.5%) in the NPG (P=0.597). A significantly higher number of women in PEG (97 of 212, 45.8%) knew it can be prevented compared to 66 of 200 (33%) in NPG (P= 0.008). Only 35 (16.5%) of PEG women knew about screening tests for toxoplasma infection, and their main source of information on toxoplasmosis was healthcare professionals and family/friends compared with NPG women who got information through newspapers/books. PEG Women exhibited enhanced preventive behavior towards toxoplasmosis. Nearly 50% of all PEG participants lacked basic knowledge towards toxoplasmosis but >90% of them avoided most high-risk activities during their pregnancy. In addition, this is the first study in the Middle east conducted through an online survey to collect relevant information related to toxoplasmosis from pregnant women. Conclusions: This study highlights inadequate knowledge and preventive behavior towards toxoplasmosis among Kuwaiti women. Thus, health education on toxoplasmosis should be offered to all adult/pregnant women to reduce congenital toxoplasmosis.

A new design method for maximally flat IIR fullband differentiators with flat group delay responses is derived in this paper. The design method starts from the flatness conditions of magnitude response and group delay response at the origin. After mathematical manipulations it shows that presented design method reduces to solving the system of linear equations. By increasing the orders of polynomials in numerator and denominator, degrees of flatness are increased, that is improvement in magnitude responses and group delay responses in terms of flatness is obtained.

Highlights • Supernumerary penises is an extremely rare congenital anomaly. • It affects one in every 5–6 million live births. • Each case has a unique presentation and no cases are identical. • Around 100 cases of diphallia are reported till now. • No cases of Triphallia is reported before., Introduction Supernumerary penises is an extremely rare congenital anomaly which affects one in every 5–6 million live births. Affected patients may have only a rudimentary penis, supernumerary penile glances or complete duplication or triplication of penises. Some patients may have some other associated congenital anomalies. Presentation of case A 3-month-old child presented because of left side hydrocele. There were evidence of two supernumerary penises in the perineum, the first one was about 2 cm in length with a glans and was attached to the root of the penis, and the third one was about 1 cm and was below the scrotum. Hydrocelectomy was performed. The two supernumerary penises were extending to perineal region and were attached to original penis, both had corpora cavernosum and spongiosum with no urethra inside. Both supernumerary penises were excised and both corpora were sutured with a fine slowly absorbable suture material. The patient was discharged with no postoperative events and follow up was done for one years with no reported adverse events. Conclusion Triphallia (three penises) is unreported condition in human until now. Patients with supernumerary penises have unique presentation and no cases are identical. The position of the penis may be ectopic or orthotopic. Treatment is difficult because it poses medical, ethical, and cosmetic aspects. A combined multidisciplinary team is required for the management and long term follow up is required. Excision or reconstruction of the duplicate penis is required depending on the corporal development and anatomy of the urethra.

Congenital agenesis of the gall bladder is a very rare ranging from 0.02% to 0.002% in clinical practice. There is complete absence of the gall bladder with normal intra and extra hepatic biliary tree. The exact etiology remains unclear. Low index of suspicion and failure of routine investigations will result in its unexpected discovery during surgery. The condition usually results in diagnostic dilemma both before surgery and intraoperatively. A 25-year-old lady presented with repeated attacks of right side abdominal pain for 1 year. Abdominal examination showed tenderness on palpation in the right hypochonrdium. Abdominal ultrasound showed normal common bile duct with suspicion of small contacted gall bladder. MRCP showed extrahepatic biliary tree and not visualized gall bladder. During diagnostic laparoscopy exploration of the whole peritoneal cavity was performed. The gall bladder was not visualized after complete visualization of biliary anatomy. The appendix was inflamed with multiple adhesions with the bowel. The cecum was high placed in the sub-hepatic region. Laparoscopic appendicectomy was performed. Patients with gall bladder agenesis surprisingly have symptoms similar to cholecystitis, the pain may be attributed to cholangitis, biliary stones, or sphincter of Oddi dysfunction. When the condition diagnosed at operation extensive dissection to identify the gall bladder must be avoided because it may result in biliary injury., Highlights • Congenital agenesis of the gall bladder is a very rare. • Many patients surprisingly have symptoms similar to cholecystitis. • Extensive dissection to identify the gall bladder must be avoided because it may result in biliary injury.

Portal hypertension is an increase in the portal venous pressure resulting in the formation of dilated veins at the site of porto-systemic venous anastomosis causing shifting of the blood flow from the portal venous system to the systemic circulation. A 53-year-old male presented to the emergency department complaining from hematemesis. He was admitted to the emergency department. Abdominal examination showed hugely dilated veins in the abdominal wall with palpable spleen and liver. The hemoglobin level was low and liver enzymes were mildly elevated. The patient received two units of blood and four units of fresh frozen plasma, intravenous propranolol and intravenous vasopressin. Endoscopy showed variceal bleeding which was mild, multiple bandings were performed for the bleeding vessels. The past medical history was negative apart from idiopathic portal vein thrombosis. He was on regular anticoagulants and beta blockers. The patient was prepared to undergo surgical shunting procedure. Acute variceal bleeding is a medical emergency, and patients need aggressive form of treatment. Most drugs like beta-blockers, derivatives of vasopressin and somatostatins work by inducing splanchnic vasoconstriction and decrease the portal venous pressure. Endoscopic band ligation may be required but this has no effect on the portal venous pressure, other alternatives include trans-jugular intrahepatic portosystemic shunts or surgery., Highlights • Caput medusae sign is a clinical sign indicating portal hypertension. • It results from shifting of blood flow from the portal venous system to the systemic circulation. • This results in the formation of dilated veins at the site of porto-systemic venous anastomosis. • Portal hypertension results in splenomegaly, ascites, esophageal and gastric varices.