0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Special Feature |

Image of the Month—Quiz Case FREE

John Kubasiak, BA; John Linn, MD; Marie Crandall, MD, MPH
[+] Author Affiliations

Author Affiliations: Northwestern University Feinberg School of Medicine, Chicago, Illinois.


SECTION EDITOR: CARL E. BREDENBERG, MD


Arch Surg. 2011;146(9):1095. doi:10.1001/archsurg.2011.241-a.
Text Size: A A A
Published online

A 75-year-old man presented to the emergency department with 2 days of sudden-onset abdominal pain, nausea, and 1 episode of hematemesis. He had been obstipated for a similar period. He described his pain as epigastric with substernal radiation. Review of systems was otherwise negative.

Abdominal examination revealed a distended abdomen with absent bowel sounds. A mass was palpable in the upper abdomen, and peritoneal signs were present. Cardiopulmonary examination was normal. Vital signs and laboratory results showed a temperature of 38°C, white blood cell count of 22 000/μL (to convert to ×109/L, multiply by 0.001) with 92% neutrophils, hemoglobin level of 16.3 g/dL (to convert to grams per liter, multiply by 10), a total bilirubin level of 3.2 mg/dL (to convert to micromoles per liter, multiply by 17.104), and a direct bilirubin level of 0.8 mg/dL (to convert to micromoles per liter, multiply by 17.104). Computed tomographic scan with contrast of the chest and abdomen was obtained (Figure 1 and Figure 2). Fluid resuscitation was initiated.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Computed tomographic scan of the abdomen, sagittal cut.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Computed tomographic scan of the abdomen.

He was taken to the operating room for endoscopy and laparotomy. Esophagoscopy revealed a linear tear of the esophageal mucosa at the Z line. No mass lesion or transmural perforation was identified. Laparotomy revealed a large, soft, inflammatory mass involving the jejunum approximately 60 cm distal to the ligament of Treitz. The proximal small bowel was clearly obstructed. He underwent small-bowel resection with primary anastomosis. The stomach and the gastroesophageal junction were then submerged with saline. A nasogastric tube was used to insufflate air into the stomach, and no bubbling was detected, so nothing further was done to that area. The patient had an uneventful recovery and tolerated a general diet prior to hospital discharge. He was seen in follow-up 3 weeks after surgery with no complications.

WHAT IS THE DIAGNOSIS?

A.  Non-Hodgkin lymphoma of the small bowel

B.  Metastatic gastric cancer

C.  Jejunal diverticulum with localized abscess

D.  Crohn disease with abscess formation

Figures

Place holder to copy figure label and caption
Graphic Jump Location

Figure 1. Computed tomographic scan of the abdomen, sagittal cut.

Place holder to copy figure label and caption
Graphic Jump Location

Figure 2. Computed tomographic scan of the abdomen.

Tables

References

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles