Closed loop obstruction
49 year old male presents with abdominal pain and distension. Past history of appendicectomy.
CT abdomen and pelvis
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Within the right iliac fossa, there is a closed loop obstruction of a portion of small bowel. The involved small bowel is distended and fluid filled. A portion of the involved small bowel demonstrates reduced mucosal enhancement. No pneumatosis intestinalis. There is a swirling pattern of the mesenteric vessels entering this closed loop obstruction. There is localised free intraperitoneal fluid within the right iliac fossa, as well as a thin rind of fluid surrounding the liver.
The large bowel has an unremarkable appearance. The upper abdominal solid organs are unremarkable. The portal vein opacifies normally. No portal vein gas. No free intraperitoneal gas.
Closed loop obstruction of small bowel within the right iliac fossa. A portion of small bowel involved in this closed loop obstruction demonstrates hypoenhancement, concerning for ischaemic bowel. The aetiology of the closed loop obstruction is favoured to be secondary to small bowel volvulus due to the swirling pattern of the mesenteric vessels.
The patient was taken for emergency laparotomy, which showed small bowel volvulus deep to an adhesion within the right iliac fossa (presumed secondary to the previous history of appendicectomy). Upon relief of the volvulus, a short 10 cm segment of small bowel was found to be infarcted, corresponding to the segment of hypoenhancing bowel identified on CT.