Presentation
Acute onset of abdominal distension, vomiting and absence of bowel motion.
Patient Data
A soft tissue attenuating "mass" seen occupying the central abdomen and exerting mass effect displacing some of the air-filled bowel loops to the periphery.
No pneumoperitoneum.
Diffuse loops of dilated and obstructed proximal small bowel with closed loop/mushroom configuration. Two adjacent transition points entering and exiting the closed loop, best seen on sagittal reformats. Significant amount of mesenteric fluid.
The proximal half of dilated small bowel loops (jejunum) appears to have marked reduction in its bowel wall enhancement, highly suspicious of bowel ischemia.
No pneumoperitoneum, intramural gas or portal venous gas.
The distal ileum and colon are mostly collapsed.
Large degree of ascites.
Tight neck of the internal hernia (two red arrows) showing (green arrows) the entry and exit loops resulting in a closed loop obstruction of the small bowel loops.
Case Discussion
CT imaging features are in keeping with closed loop obstruction as we can identify two transition points (both entering and exiting bowel loops). It is considered surgical emergency as the risk of bowel ischemia is very high.
Patient went on to have emergency laparotomy. Intraoperatively, upon entering peritoneum, 1.2 liters of haemoserous fluid evacuated. Root of small bowel mesentery twisted 360 degrees due to constricting adhesion. Both proximal and distal bowels are collapsed. 160cm of non viable small bowel resected.
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