Endgames Picture quiz

An elderly woman with obstruction

BMJ 2009; 339 doi: http://dx.doi.org/10.1136/bmj.b3641 (Published 23 September 2009) Cite this as: BMJ 2009;339:b3641
  1. Anna Tilley, foundation year 1 1,
  2. Adib Khanafer, specialist registrar in vascular surgery 1,
  3. Abhijoy Chakrabarty, specialist registrar in vascular surgery 1,
  4. Ravivarma Balasubramaniam, specialist trainee in surgery1,
  5. Peter Waterland, specialist trainee in surgery1,
  6. Tony Fox, consultant vascular surgeon1
  1. 1Royal Shrewsbury Hospital, Shrewsbury SY3 8XQ
  1. Correspondence to: A Tilley anna.tilley{at}imperial.ac.uk

    A thin, 87 year old, white woman presented with absolute constipation that had lasted for three days, abdominal pain, and vomiting. She also complained of a severe pain in her right thigh radiating to the knee. She had no preceding bowel symptoms, but she reported bouts of vomiting and abdominal pain lasting several days for the previous 18 months. The patient was unsure of recent weight loss. She lived alone and was independent, although her daughter helped with shopping.

    Medical history included osteoporosis and occasional dyspepsia. The patient had no history of any abdominal surgery. Medications were weekly risedronate and daily omeprazole. On examination she had a distended and tender abdomen with no palpable masses or hernias. Bowel sounds were high pitched and “tinkling.” She also demonstrated right sided painful hip flexion. Abdominal radiography revealed dilated loops of small bowel suggestive of obstruction, and computed tomography of the abdomen was requested (fig 1).

    Fig 1 Computed tomogram of the patient’s abdomen

    Questions

    • 1 What are the differential diagnoses for this patient?

    • 2 Describe any abnormality seen on computed tomogram.

    • 3 What is the most likely diagnosis?

    • 4 What factors can predispose to this condition?

    • 5 What classic sign was elicited during the examination, and what other signs would you look for that could aid diagnosis?

    Answers

    Short answers

    • 1 This patient’s bowel obstruction could be caused by neoplasia, hernia, inflammatory stricture, volvulus, or congenital band adhesion.

    • 2 Small bowel can be seen in the right obturator foramen on the computed tomogram.

    • 3 This patient has an obstructed obturator hernia.

    • 4 …

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