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A 52-year-old man presented to the emergency department complaining of an 8-hour history of progressive, crampy, epigastric, and periumbilical abdominal pain. He reported nausea but no vomiting. He continued to pass flatus and had a normal bowel movement the day prior to admission. On presentation, the patient was afebrile with normal vital signs. Physical examination was significant for high-pitched bowel tones, mild abdominal distention, and diffuse tenderness without peritoneal signs. Laboratory studies showed leukocytosis (14 500 cells/mL) with elevated bands. Acute abdominal series showed multiple dilated small-bowel loops with air-fluid levels. Computed tomography scans of the abdomen and pelvis showed dilation of the stomach and small bowel and distal decompressed bowel in the pelvis with a transition point in the left lower quadrant. Diagnostic laparoscopy revealed a loop of distal small bowel herniating through an approximately 4-cm defect in the medial peritoneal leaflet of the sigmoid mesocolon (Figure 1and Figure 2).
Taras A, Martinez R. Image of the Month—Quiz Case. Arch Surg. 2009;144(12):1187–1188. doi:10.1001/archsurg.2009.200-a
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