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A previously fit 24-year-old man presented with a 3-week history of colicky lower abdominal pain and constipation. His last bowel movement was 6 days prior to presentation. He had undergone an appendectomy 4 years previously. Laparotomy at that time had revealed a gangrenous perforated appendix.
On examination, the man was tender in the left iliac fossa with guarding. His abdomen was dull to percussion at the flanks and shifting dullness could be elicited. He had a pulse of 100 beats/min and a blood pressure of 100/70 mm Hg. Initial serological investigation showed marked leukophilia with a white blood cell count of 8300/μL. He was fluid resuscitated and underwent an emergent diagnostic laparotomy (Figure 1and Figure 2).
Grossly dilated loops of the small bowel with fibrous adhesions along its length.
Meckel diverticulum in the right iliac fossa.
At laparotomy, 1500 mL of frank pus was aspirated from the peritoneal cavity. There was gross dilation of the small bowel up to and including the ileum, suggestive of small-bowel obstruction. There were fibrous adhesions along the length of the small and large bowel (Figure 1and Figure 2).
B. Internal hernia
D. Inflammatory stricture
Uzoigwe CE, Bitra K, Munot K, Griffith JP, Davies JB. Image of the Month—Quiz Case. Arch Surg. 2007;142(5):485. doi:10.1001/archsurg.142.5.485