Endgames Picture quiz

Something’s in the air

BMJ 2009; 338 doi: https://doi.org/10.1136/bmj.b425 (Published 12 March 2009) Cite this as: BMJ 2009;338:b425
  1. Martin H de Borst, specialist registrar1,
  2. Marjolein E M Lacor, specialist registrar1
  1. 1Leeuwarden Medical Centre, Department of Medicine, PO Box 888, 8901 BR Leeuwarden, Netherlands
  1. Correspondence to: M H de Borst martin.de.borst{at}znb.nl

    An 80 year old woman reported abdominal pain, nausea, and vomiting, and absence of defecation for 14 days. She had no medical history. Before this she had passed stools daily, and stools were of normal consistency, without blood or mucus.

    On examination, the abdomen was slightly distended with rare, loud bowel sounds and diffuse tenderness. The upper abdomen was hypertympanous with dampened percussion in the left lower abdomen. Rectal examination found hardened faeces in the rectum.


    • 1. What do the arrows in the right upper quadrant of the figure show?

    • 2. What do the arrowheads in the left lower quadrant show?

    • 3. How do these findings explain the patient’s symptoms?

    • 4. What definitive management can be offered?


    Short answers

    • 1. The arrows in figure 1 show pneumobilia (air in the biliary tree), a common finding after …

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