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May 2011May 16, 2011

Image of the Month—Quiz Case

Author Affiliations

Author Affiliations: General and Thoracic Surgery, Seattle Children's Hospital and the University of Washington, Seattle.

Arch Surg. 2011;146(5):629. doi:10.1001/archsurg.2011.107-a

A 4-year-old boy developed severe, sharp, periumbilical abdominal pain followed by 4 bouts of nonbilious emesis and a loose bowel movement. He presented to an outside emergency department where a computed tomographic scan demonstrated dilated bowel (Figure 1). After a fluid bolus and insertion of a nasogastric tube, he was transferred to our institution and brought to the operating room. Laparotomy revealed that the bowel was twisted on the mesentery. Whitish fluid was present in the abdomen (with a triglyceride level of 3607 mg/dL [to convert to millimoles per liter, multiply by 0.0113]). There was similarly whitish discoloration of the entire small-bowel mesentery that followed the lymphatic channels from the bowel to the mesentery interface (Figure 2).

Figure 1. 
Computed tomographic scan.

Computed tomographic scan.

Figure 2. 
Operative image.

Operative image.

What is the Diagnosis?

A. Tuberculosis

B. Mesenteric lymphangiomatosis

C. Midgut volvulus

D. Mesenteric lipoma