Presentation
Recurrent abdominal pain, nausea, vomiting after admission for small bowel obstruction managed with nasogastric decompression.
Patient Data
Proximal small bowel is decompressed. Short segment dilated small bowel in the right mid abdomen which transitions into decompressed loops in the pelvis with mesenteric edema. Although difficult to follow, the terminal/distal ileum transitions retrograde into the segment by draping over the proximal transition (seen better in the follow up study).
Pancreas transplant appears normal. Septate versus bicornuate uterus.
Dilated stomach and proximal small bowel filled with oral contrast. Rapid transition in the right lower quadrant with angulation of small bowel leading into decompressed loops in the pelvis. Some mesenteric edema associated with these loops. Following the TI backward from the cecum, there is a second transition point which drapes over the first transition point and falls into the pelvis, leading into a mildly dilated loop containing oral contrast.
RLQ pancreas transplant appears normal.
Annotated images of transitions into and out of the closed loop segment.
Case Discussion
Operation: Lysis of adhesions with reduction of closed-loop obstruction.
Operative details (edited): "adhesive band involving the proximal jejunum overlying the head of the pancreas allograft and duodenojejunostomy resulting in an internal-hernia type configuration. All of the small bowel distal to this area were decompressed and normal. This adhesive band and several others were lysed which fully relieved the obstruction."
A very challenging case of recurrent small bowel obstruction in which the patient developed worsening symptoms after attempted management with nasogastric decompression. In this case, the proximal small bowel transitions in the right lower quadrant into the distal decompressed small bowel that is clustered in the pelvis with mesenteric edema. It is not possible to follow this small bowel in its entirety to the cecum. However, you can follow the TI back from the cecum into this cluster, and doing so reveals a second transition point into this cluster in the pelvis, in which the distal ileum wraps around the upper margin of the first transition point. This indicates a closed-loop configuration. It is very challenging to determine this in the first study, and oral contrast helps clarify the anatomy further. Additionally, appreciate how on the coronal images there is traction on the mesenteric vasculature toward the pelvic small bowel loops as there are confined by the adhesive bands as opposed to more freely moving within the pelvis.
The presentation study is exceptionally challenging to interpret. What might raise red flags about an unusual presentation is the fact that the proximal small bowel is normal, and that there is a short segment of dilated small bowel leading into such a long segment of relatively clustered small bowel with mesenteric edema. Attempting to explain this edema is very challenging without considering venous congestion from compression by an adhesive band. The loops are not thickened or hyperenhancing which might support infectious enteritis as an alternative. If encountering a challenging case like this at presentation, it can be helpful to directly explain to the surgeons what you see and what you can and cannot explain, and recommend close clinical monitoring with a low threshold for repeated imaging, as the passage of a small amount of time might elucidate the diagnosis.
Unable to process the form. Check for errors and try again.