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OpenAthens Shibboleth
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Special Feature
Mar 2012

Image of the Month—Quiz Case

Author Affiliations


Author Affiliations: Division of Transplantation, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston.

Arch Surg. 2012;147(3):291. doi:10.1001/archsurg.2011.670a

A 63-year-old man with history of diabetes mellitus and liver transplantation 2 years prior to admission visited the hospital with severe abdominal pain, jaundice, and vomiting 2 days after endoscopic retrograde cholangiopancreatography for investigation of increasingly abnormal liver function test results. The patient had no history of cardiac disease and there was no history of fever in the last days prior to admission. Physical examination revealed diffuse abdominal tenderness but no rebound tenderness or guarding. Vital signs were normal except for tachycardia (heart rate, 120 beats/min). Laboratory test results were remarkable for total bilirubin level (32.2 mg/dL; to convert to micromoles per liter, multiply by 17.104) and lactate level (157.7 mg/dL; to convert to millimoles per liter, multiply by 0.111). Computed tomography of the abdomen and pelvis was performed (Figure 1).

Image not available

Figure 1. Coronal computed tomographic scan of the abdomen. I indicates inferior; S, superior.

What Is the Diagnosis?

A.  Acute mesenteric thrombosis and embolism

B.  Duodenal perforation during endoscopic retrograde cholangiopancreatography

C.  Perforated diverticulitis

D.  Portal vein gas associated with pneumatosis intestinalis