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Special Feature
Oct 2011

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Departments of Digestive Surgery and Liver Transplantation (Drs Lubrano, Paquette, Idelcadi, and Mantion) and Medical Imaging (Dr Delabrousse), Besançon University Hospital, Besançon, France.

Arch Surg. 2011;146(10):1215. doi:10.1001/archsurg.2011.261-a

An 89-year-old man was referred to our surgical emergency department by his physician for acute abdominal pain that had lasted 8 hours with vomiting. He had hypertension but no history of previous abdominal surgery. At admission, his vital signs were normal, and no fever was noted. Neurological examination results were normal. Abdominal physical examination revealed diffuse abdominal pain—more acute in the epigastrium—without a palpable mass. Blood chemistry screening results showed a white blood cell count of 10.9/μL and a C-reactive protein level of 5 mg/L. (To convert the white blood cell count to cells ×109 per liter, multiply by 0.001; to convert the C-reactive protein level to nanomoles per liter, multiply by 9.524.) Liver and pancreatic function test results were normal. Contrast-enhanced computed tomography of the abdomen showed C-shaped bowel loops within the left upper quadrant associated with mesenteric infiltration, the absence of bowel wall enhancement, and a mesenteric whirl sign located anterior to the left lobe of the liver (Figure 1).

Image not available

Figure 1. Contrast-enhanced computed tomography of the abdomen showing C-shaped bowel loops within the left upper quadrant. A indicates anterior; F, feet; L, left; P, posterior; and R, right.

What Is the Diagnosis?

A.  Left paraduodenal hernia

B.  Small-bowel volvulus due to an adhesive band

C.  Internal hernia through the left hepatic triangular ligament

D.  Transomental hernia