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A 74-year-old man was admitted to the emergency department presenting with a history of recurrent vomiting and colicky pain in the right lower abdominal quadrant radiating to the right upper quadrant and groin. He had a history of nonrecurrent diverticulitis and chronic constipation. The patient's surgical history included open cholecystectomy 24 years ago.
On examination, the patient was afebrile and hemodynamically stable. However, a tenderness of the lower right quadrant and high-pitched bowel sounds were revealed. Laboratory test results showed a leukocytosis with a white blood cell count of 20 900/μL (to convert to ×109/L, multiply by 0.001) (normal, <10 500/μL) and an elevated C-reactive protein level of 16.7 mg/L (to convert to nanomoles per liter, multiply by 9.524) (normal, <5 mg/L) while the liver function test results were normal.
A computed tomographic scan was performed (Figure 1).
Coronal reconstructions of a computed tomographic scan of the abdomen showing dilated loops of small bowel and diverticulosis of the small and large intestine with a diverticulum of 38 mm in diameter in the duodenum (asterisk). A cockade (arrow) was revealed within the distal small bowel.
B. Perforated diverticulitis
C. Bouveret syndrome
D. Gallstone ileus
Kaderli R, Fahrner R, Beldi G, Patak MA, Candinas D. Image of the Month—Quiz Case. Arch Surg. 2011;146(6):759. doi:10.1001/archsurg.2011.140-a