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Special Feature
February 2011February 21, 2011

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: Departments of Surgery (Drs Al-Mufarrej, Kaza, Abell, and Brody) and Anesthesiology and Critical Care Medicine (Dr Ahari), The George Washington University Medical Center, Washington, DC.




Copyright 2011 American Medical Association. All Rights Reserved. Applicable FARS/DFARS Restrictions Apply to Government Use.2011

Arch Surg. 2011;146(2):233. doi:10.1001/archsurg.2010.344-a

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).

Figure 1.
Image not available

Noncontrast computed tomogram of the abdomen shows the upper (A) and lower (B) cuts. See text for description of arrows.

Figure 2.
Image not available

Laparoscopic view of the left upper abdomen.

What Is the Diagnosis?

A.  Small-bowel volvulus

B.  Paraduodenal hernia

C.  Malrotation

D.  Enteric duplication cyst