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⇓).