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Special Feature
June 2011

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: Division of Visceral Surgery and Transplantation, Department of Surgery (Drs Kaderli, Fahrner, Beldi, and Candinas), and Institute of Diagnostic, Interventional, and Pediatric Radiology (Dr Patak), University Hospital Bern, Bern, Switzerland.




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

Arch Surg. 2011;146(6):759. doi:10.1001/archsurg.2011.140-a

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).

Figure 1
Image not available

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.

What Is the Diagnosis?

A.  Intussusception

B.  Perforated diverticulitis

C.  Bouveret syndrome

D.  Gallstone ileus