Author Affiliations: Department of Surgery, Baptist Memorial Hospital, Memphis, Tennessee.
A 46-year-old woman presented to the emergency department with acute-onset right upper quadrant pain of 12 hours' duration. She had noted some nausea, and her last bowel movement was the preceding day. She also noted a previous but much milder attack 1 week before admission. Her medical history was significant for rheumatoid arthritis and 2 cesarean sections. Her brother had undergone exploration for malrotation at 3 months of age. Results of her physical examination were remarkable only for marked tenderness in the epigastrium. The fetal position garnered her the most symptomatic relief. There was no leukocytosis. After administration of oral and intravenous contrast, computed tomography (CT) of the abdomen was performed, revealing a distended, gas- and stool-filled loop of colon in the mid upper abdomen with the stomach displaced laterally and anteriorly. There was periportal edema with narrowing of the portal vein at the porta hepatis (Figure 1). The patient underwent diagnostic laparoscopy (Figure 2).
Figure 1. Periportal edema and narrowing of the portal vein. The stomach is displaced anteriorly.
Figure 2. Operative view of herniated colon traversing beneath the hepatoduodenal ligament.
A. Duodenal diverticulum
B. Cecal volvulus
C. Foramen of Winslow hernia
D. Pancreatic pseudocyst
Grisham A, Javan R. Image of the Month—Quiz Case. Arch Surg. 2011;146(11):1329. doi:10.1001/archsurg.2011.279-a