Presentation
Severe upper abdominal pain and vomiting one day ago. History of sleeve gastrectomy one year ago.
Patient Data
Left upper abdomen abnormal cluster of dilated proximal jejunal loops that measure about 4 cm mean diameter distended with fluid and to a lesser degree gas contents with surrounding mesenteric fat edema, vascular swirling, and congestion.
These loops have increased wall density in the plain study and hypo-enhance in the post-contrast study, probably related to wall edema, hemorrhage, or ischemia.
Sleeve gastrectomy changes with dilated stomach and duodenum opacified with oral contrast. No passage of oral contrast beyond the duodenum.
The rest of the small and large bowel loops are not distended.
Small to medium volume ascites.
Intraoperative photo 1 shows the discolored obstructed loops.
Intraoperative photo 2 shows the color difference between the normal (blue arrow) and diseased loops (black arrow).
No current cluster of dilated bowel loops.
The previously involved small bowel loops appear mildly distended and adequately opacified, with mild wall and mucosal thickening.
The mesenteric fat planes are still blurred, congested, and edematous.
Postoperative pneumoperitoneum.
Free passage of oral contrast through most of the small bowel segments with no definite enteric contrast leak.
Intraperitoneal drains with no current ascites.
The lower chest slices show bilateral patchy pneumonitis.
Case Discussion
The diagnosis was confirmed intraoperatively to be secondary to an adhesive band thought to be related to the sleeve gastrectomy. Adhesiolysis was readily performed; however, the question was about the bowel wall status and whether it was ischemic or not. The surgeon started hot fomentation aiming to revitalize the bowel wall, which succeeded to a great extent. He chose this option as the involved bowel loops were immediately distal to the duodenojejunal junction which is a difficult and risky site for resection and anastomosis.
The case required CT follow-up for assessment of the bowel wall status and showed that the bowel recovered well postoperatively.
Picking up a closed-loop obstruction is not the only role of imaging; commenting on the bowel wall status is also a very important imaging role.
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