Presentation
Severe generalized abdominal pain, bowels not opened for 48 hours.
Patient Data
CT A/P with portal venous phase contrast
There are multiple dilated and fluid-filled loops of small bowel, in keeping with obstruction. In the mid-small bowel, a closed-loop segment is demonstrated, better appreciated on the coronal view. Abrupt narrowing is present at both ends of this short loop, which has a C-shape on the coronal images. The wall of this segment enhances less than the remaining small bowel, indicating bowel ischemia. A small blind-ending sac is noted to arise just posterior to the abruptly narrowed bowel, the nature of this is unclear. The small bowel loops downstream to the transition point are collapsed. There is free intraperitoneal fluid. No pneumoperitoneum.
Diagnosis: Mechanical (closed loop) bowel obstruction with ischemia.
Mechanical (closed loop) bowel obstruction with ischemia. Histology also revealed the presence of a thin walled and ischemic diverticulum, in keeping with a Meckel diverticulum.
Case Discussion
This is a case of closed-loop obstruction as the transition points are in close proximity to each other (double beak sign) which is complicated by ischemia, evident from the change in bowel wall enhancement within the closed loop, mesenteric congestion and fluid. There is also the additional finding of a blind-ending loop, which was confirmed to be a Meckel's diverticulum on histology. The patient was taken to theater and underwent resection of the ischemic portion of the bowel. An internal hernia was thought to be the cause of the obstruction.
Histology:
The resected small bowel demonstrates acute hemorrhagic ischemic necrosis. A diverticulum is noted which is thin walled and ischemic, which would be in keeping with a Meckel's diverticulum. No gastric or pancreatic mucosa is noted.
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