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Special Feature
February 2008

Picture of the Month—Quiz Case

Author Affiliations

Author Affiliations:Division of Emergency Medicine (Dr Mittal) and Department of Pediatric Surgery (Dr Pimpalwar), The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; and Department of Pediatrics, University of Pennsylvania School of Medicine, Philadelphia (Dr Mittal).

 

Samir S.ShahMDAlbert C.YanMD

Arch Pediatr Adolesc Med. 2008;162(2):181. doi:10.1001/archpediatrics.2007.17-a

A 16-year-old boy presented to the emergency department with severe, diffuse, continuous abdominal pain for 2 days. There was no history of fever or vomiting. His last bowel motion was 2 days back. He was seen at an outside hospital the previous day, diagnosed as having constipation, and prescribed stool softener (Metamucil; Procter & Gamble, Cincinnati, Ohio) that did not result in any relief. There was no significant past or family history. On examination, his vital signs were normal. His abdomen showed mild diffuse tenderness, but no rigidity. There was no mass. Bowel sounds were present. A radiograph of the abdomen (Figure 1) was obtained. A therapeutic procedure in the emergency department resulted in alleviation of pain. The patient was admitted to the hospital for observation, where pain recurred the next day, when a barium enema (Figure 2and Figure 3) was used to confirm the diagnosis.

Figure 1.
A radiograph of the abdomen was obtained, showing a markedly distended sigmoid colon with an inverted U-shaped appearance; the limbs of the sigmoid loop are directed toward the pelvis, while the other end enters the left upper quadrant.

A radiograph of the abdomen was obtained, showing a markedly distended sigmoid colon with an inverted U-shaped appearance; the limbs of the sigmoid loop are directed toward the pelvis, while the other end enters the left upper quadrant.

Figure 2.
A barium enema was used for the diagnosis: barium enters the empty rectum and encounters stenosis, giving rise to a beaklike appearance, the so-called bird's beak or bird-of-prey sign.

A barium enema was used for the diagnosis: barium enters the empty rectum and encounters stenosis, giving rise to a beaklike appearance, the so-called bird's beak or bird-of-prey sign.

Figure 3.
A barium enema was used for the diagnosis: “beaking” of 2 loops of adjacent bowel is shown, signifying a twist of the sigmoid colon.

A barium enema was used for the diagnosis: “beaking” of 2 loops of adjacent bowel is shown, signifying a twist of the sigmoid colon.

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