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Special Feature
Feb 2012

Image of the Month—Quiz Case

Author Affiliations


Author Affiliation: Department of General Surgery, Waynesboro Hospital, Waynesboro, Pennsylvania. Dr McKee is now with the Department of General Surgery, Heritage Valley Health System, Beaver, Pennsylvania.

Arch Surg. 2012;147(2):195. doi:10.1001/archsurg.2011.642

A 71-year-old woman had a sudden onset of what she described as a “tummy ache” at 9 PM the evening prior to admission to the hospital. The midabdominal discomfort progressively worsened to severe abdominal pain with associated back pain. She had vomiting without hematemesis. There was no history of hematochezia or melena, and she had a normal bowel movement the previous day. She was receiving treatment with warfarin sodium for a history of atrial fibrillation. Formerly weighing 144.0 kg, she attributed a weight loss of 60.8 kg over 8 years to exercise and a diet plan that included a lot of fiber. Although she had diverticulosis noted on a colonoscopy a few years ago, she had never had an abdominal operation. Her family history included coronary artery disease and cerebrovascular accident.

She went to the hospital early the next morning and was seen by the emergency department physician, who consulted me after the patient's imaging report was obtained. On examination, the patient had a regular heart rate and rhythm, and her abdomen was soft with mild to moderate diffuse abdominal tenderness. Laboratory evaluation revealed a normal complete blood cell count, including a white blood cell count of 5900/μL (to convert to ×109 per liter, multiply by 0.001). Her amylase level was normal at 44 IU/L (to convert to microkatals per liter, multiply by 0.0167) and her lactic acid level was normal at 19.8 mg/dL (reference range, 4.5-19.8 mg/dL; to convert to millimoles per liter, multiply by 0.111). Prothrombin time was elevated at 21.9 seconds, with an international normalized ratio of 2.1. Concerned about an abdominal catastrophe, the emergency department physician ordered an abdominal computed tomographic scan without oral contrast (Figure 1).

Figure 1. Computed tomographic scan of the abdomen.

Figure 1. Computed tomographic scan of the abdomen.

Prior to being taken to the operating room, the patient was given 4 units of fresh frozen plasma. At laparotomy, ischemic bowel was found as well as the finding seen in Figure 2.

Figure 2. Finding at laparotomy.

Figure 2. Finding at laparotomy.

What Is the Diagnosis?

A.  Superior mesenteric artery embolus

B.  Midgut volvulus

C.  Superior mesenteric artery compression syndrome

D.  Paraduodenal hernia