What is causing the patient's intra-abdominal pain?

Each month, Dr. Maria Flynn issues a Radiology Challenge, presenting images from one of a variety of imaging modalities and a case report. Can you diagnose the condition? Follow the link to find out whether your answer was correct, what was really wrong with the patient, and how the patient was treated. Then, come back next month to test your radiographic reading skills on a new case!

Maria Flynn, MD

GU Imaging Chief

Radiology Intern Program Director

Department of Radiology

Naval Medical Center Portsmouth

Portsmouth, VA

Robert C. Scalise

MS4

Edward Via Virginia College of Osteopathic Medicine

Blacksburg, VA

Dr. Maria Flynn is Chief of Genitourinary Imaging and Radiology Intern/Medical Student Program Director at the Naval Medical Center Portsmouth, as well as a Lieutenant Commander in the US Navy Medical Corps. She received her medical degree from Tulane Medical School in 1994 and completed her radiology residency at the National Capital Consortium in 2003. She is certified by the American Board of Radiology and has been appointed Adjunct Assistant Professor of Radiology and Radiological Sciences at the F. Edward H?bert School of Medicine.

Case report

A 42-year-old woman presented to the emergency department complaining of crampy abdominal pain, nausea, and vomiting that worsened with eating. She reported experiencing similar episodes, which occurred at approximately 6-month intervals over the previous 6 to 7 years. Her surgical history included multiple ventral hernia repairs, a laparoscopic Roux-en-Y gastric bypass (RYGB) in 1996, abdominoplasty, and an abdominal hysterectomy.

Prior medical records were unavailable; however, the patient claimed to have been admitted to the hospital on three occasions for abdominal pain. During one admission, she underwent an exploratory laparotomy, which was significant for a volvulus within an internal hernia.

A physical examination found the patient to be hemodynamically stable. Her abdomen was diffusely tender and distended, with no peritoneal signs. Bowel sounds were hyperactive. Laboratory tests found a white blood cell (WBC) count of 13.1 x 103/?L, and urinalysis findings were noncontributory. Contrast-enhanced computed tomography (CECT) of the abdomen and pelvis was performed (Figures 1-4).

Challenge: What is causing the patient's intra-abdominal pain?

a) Complete small bowel obstruction

b) Volvulus

c) Intussusception with partial small bowel obstruction

d) Mesenteric ischemia

e) Internal hernia