Image of the Month—Quiz Case

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 

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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.

A.  Intussusception

B.  Perforated diverticulitis

C.  Bouveret syndrome

D.  Gallstone ileus

Answer