Presentation
Dementia, poor historian. 3 days of vomiting and diffuse abdominal pain.
Patient Data
The stomach and proximal small bowel are severely distended and fluid-filled. The small bowel tapers abruptly within the right lower quadrant posterolateral to the cecum. At this location, a partially distended short segment of small bowel forms a loop and the mesentery points to the transition point. The distal ileum and large bowel is collapsed. The bowel continues to enhance. No bowel wall thickening. No pneumatosis. Incidental dIffuse distal colonic diverticulosis.
Small locules of extraperitoneal free gas within the pelvis. No free gas within the peritoneal cavity. No free fluid. No mesenteric fat stranding.
Large mural thrombus within the supra renal abdominal aorta causing moderate stenosis. Further large regions of mural thrombus within the infrarenal abdominal aorta, causing moderate to severe stenosis. No definite dissection flap.
The celiac, superior mesenteric, and renal arteries arise from the opacified portions of the abdominal aorta. Severe stenoses of the bilateral renal arteries. Severely reduced caliber of the inferior mesenteric artery.
The renal parenchyma enhances normally. Simple cyst within the left kidney. Simple parapelvic renal cysts within the right kidney. No hydronephrosis. Bulky appearance of the bilateral adrenal glands.
The liver, spleen, and pancreas appear normal. Cholecystectomy noted. Mild dilation of the intra and extrahepatic biliary tree.
IMPRESSION
Small bowel obstruction with the transition point caused by an internal hernia within the right lower quadrant. This internal hernia involves a mid-distal segment of the ileum which forms a closed loop. The bowel continues to enhance and there is no significant wall thickening. No pneumatosis.
The source of the small locules of extraperitoneal free gas within the pelvis is unclear. Its presence suggests the possibility of a perforation (possibly of the internal hernia), however, there is no free fluid to support this.
Severe atherosclerotic changes of the abdominal aorta, with intermittent segments of moderate to severe stenosis. No evidence of a dissection flap.
Case Discussion
Laparoscopy confirmed a short loop of obstructed small bowel lateral to the cecum passing through a narrow-neck paracaecal hernia. Bowel was viable, no cause for the pneumoperitoneum found.
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