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Erect abdominal radiographs:
- marked large and small bowel distension with abnormal gas-fluid levels. Note that several grossly distended large bowel loops overlap, and in these regions (but not elsewhere) both walls of the colon are visible (see magnified key image). This is however not indicative of free gas (Rigler sign), rather its mimicker, the pseudo-Rigler sign. Note that there is no free gas under the diaphragm.
- dense content in the pelvis, representing the distended rectosigmoid bowel filled with faecal matter
- circumscribed, large, mass-like shadowing in the right lower lung zone, which does not silhouette the right heart border, thus is most likely in the lower lobe
Findings are all together in line with large bowel obstruction secondary to rectosigmoid faecal impaction and secondary small bowel ileus. The incidental right lower lung zone mass could represent a malignancy.
Conservative therapy resulted in bowel movements, nevertheless, the patient's symptoms worsened over the next few hours. Therefore a CT was requested.