Presentation
Increasing abdominal pain for 3 days. History of metastatic lung carcinoma.
Patient Data
Distended small bowel loops in the central lower abdomen. Transition points seen both up and downstream of the distension. Associated haziness of the mesentery consistent with mesenteric edema and congestion. Thickening of the wall of one of the distended loops, suggestive of developing small bowel ischemia. Scattered free fluid in the abdomen, no free gas.
Multiple enlarged peritoneal lymph nodes in the upper abdomen.
Hernia mesh in the lower anterior abdominal wall.
Large right sided pleural effusion. Collapse of the right lower lobe.
Small mass lesion demonstrated immediately superior to the collapsed lung.
Sclerotic lesion in the posterior aspect of the body of T10.
Case Discussion
Diagnosis: Closed loop obstruction with developing mesenteric ischemia.
Abrupt change in caliber both before and after the distended loop confirms presence of a closed loop obstruction. A thickened bowel loop is noted. In the presence of an obstruction and mesenteric haziness, this is highly suspicious of bowel ischemia. No evidence of perforation however, is demonstrated.
A constellation of other findings is also demonstrated, in keeping with widespread metastatic spread of the stated lung carcinoma. In light of the peritoneal deposits, this appears as the most likely cause of the obstruction.
The primary finding was confirmed at the operating theater.
Management:
- Notify clinician urgently via telephone
- Recommend CT chest for further staging
- Bone scan may be considered to better characterize skeletal involvement.
This is a good practice case for the RANZCR Film Viewing examination. The candidate is expected to recognize the closed loop nature of the obstruction and the possible mesenteric ischemia which is a surgical emergency. The likely cause is a metastatic deposit in the peritoneum or less likely, adhesion from previous hernia repair.
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