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A 42-year-old man presented with a 6-hour history of acute diffuse abdominal pain. He denied any nausea or vomiting, and his last bowel movement was a few hours prior to the onset of pain. He had no previous surgery, but his medical history was significant for intermittent, crampy abdominal pain that was rarely associated with nausea, vomiting, or change in bowel movements. Results of a prior upper endoscopy and abdominal ultrasound were normal.
On physical examination, the patient was mildly distended with no obvious surgical scars. He was tender in the left upper quadrant with no guarding or rebound. His white blood cell count was 8 × 103/μL, and his venous lactate dehydrogenase level was 0.02 U/L (to convert to microkatal per liter, multiply by 0.0167).
Subsequently, a computed tomogram of his abdomen and pelvis (Figure 1) was done, and the surgical service was consulted. The patient was advised to undergo diagnostic laparoscopy. The cause of the patient's pain was readily confirmed during the procedure (Figure 2).
Noncontrast computed tomogram of the abdomen shows the upper (A) and lower (B) cuts. See text for description of arrows.
Laparoscopic view of the left upper abdomen.
A. Small-bowel volvulus
B. Paraduodenal hernia
D. Enteric duplication cyst
Al-Mufarrej F, Kaza J, Ahari J, Abell B, Brody F. Image of the Month—Quiz Case. Arch Surg. 2011;146(2):233. doi:10.1001/archsurg.2010.344-a