Intended for healthcare professionals

Endgames Case Review

Acute constipation and vomiting with the “coffee bean” sign

BMJ 2017; 359 doi: (Published 12 October 2017) Cite this as: BMJ 2017;359:j4414
  1. Salomone Di Saverio, consultant general surgeon1,
  2. Alice Piccinini, research fellow1,
  3. Arianna Birindelli, surgical senior registrar1,
  4. Carlo Fabbri, consultant gastroenterologist2,
  5. Stefano Pretolani, consultant Internal Medicine3
  1. 1Emergency surgery, Maggiore Hospital, Bologna, Italy
  2. 2Gastroenterology and endoscopy, Maggiore Hospital, Bologna, Italy
  3. 3Gastrointestinal ultrasound, Internal medicine, Maggiore Hospital, Bologna, Italy
  1. Correspondence to S Di Saverio salo75{at}

A 44 year old woman with cerebral palsy and multiple sclerosis—which was diagnosed at the age of 16—presented to the emergency department with four days of acute constipation and vomiting.

She had a history of chronic constipation that resulted from neurogenic bowel dysfunction. The dysfunction was secondary to her underlying cerebral palsy and multiple sclerosis and was initially managed with laxatives. In the last year, the constipation had become severe enough to warrant insertion of a sacral anterior root stimulator.

On physical examination, the abdomen was markedly distended, diffusely tender, and bowel sounds were absent. There was no guarding, rigidity, or sign of previous incisions, and all hernia orifices were intact.

The patient was tachycardic (140 beats/min) and tachypnoeic, normotensive (130/60 mmHg), and had oxygen saturation in room air of SpO2 98. Arterial blood gas showed normal pH of 7.36, hypocapnea (PCO2 29 mmHg, normal range 35-45 mmHg), hyperlactataemia (20 mg/dL, 9-16 mg/dl), and no hypoxaemia (PO2 99 mmHg). White blood cell count was 10 500 cells/mm3 (73% neutrophils), and C reactive protein was 3.25 mg/dL (0-1 mg/dL).

Plain abdominal radiography (fig 1, fig 2) and a computed tomography (CT) scan were performed.

Fig 1 Plain radiograph of the abdomen (anteroposterior view)

Fig 2 Plain radiograph of the abdomen (lateral decubitus view)


  • 1. What is the most likely diagnosis?

  • 2. What differential diagnoses should be considered?

  • 3. What are the treatment options for this condition?


1. What is the most likely diagnosis?

Short answer

The plain abdominal …

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