An 84-year-old man who resided in a nursing home presented to the emergency department with a 3-week history of gradually worsening nausea, anorexia, and postprandial left upper quadrant abdominal pain with eventual food avoidance and greater than 10% weight loss. He had no difficulty passing flatus or having bowel movements. His surgical history was significant for an infrarenal abdominal aortic aneurysm repair 12 years prior to presentation. There was no known history of peptic ulcer disease, biliary disease, or malignancy. Physical examination revealed a cachectic man with a height of 1.7 m and weight of 45 kg. He was afebrile with a blood pressure of 130/70 mm Hg, pulse of 85 beats/min, respiratory rate of 22/min, and a 95% arterial oxygen saturation (SaO2) on room air. His abdomen was soft and nondistended with moderate left upper quadrant tenderness but no peritoneal signs. A midline surgical scar was well healed; no external hernias were evident. Rectal examination revealed no masses or occult fecal blood. Laboratory data and chest radiograph findings were unremarkable. A computed tomographic scan of the abdomen revealed a markedly distended stomach and dilated proximal duodenum with distal decompression. Esophagogastroduodenoscopy was performed, which revealed a narrowing of the distal portion of the duodenum with a grossly dilated stomach and proximal duodenum. There was no evidence of an intraluminal mass. An upper gastrointestinal tract barium study showed normal motility with failure of the fourth portion of the duodenum to completely opacify (Figure).
Barium contrast upper gastrointestinal tract study shows vertical opacification of the fourth portion of the duodenum.
A. Abdominal aortic aneurysm
B. Crohn's disease
C. Superior mesenteric artery syndrome
D. Gastric outlet obstruction
Thank you for submitting a comment on this article. It will be reviewed by JAMA Surgery editors. You will be notified when your comment has been published. Comments should not exceed 500 words of text and 10 references.
Do not submit personal medical questions or information that could identify a specific patient, questions about a particular case, or general inquiries to an author. Only content that has not been published, posted, or submitted elsewhere should be submitted. By submitting this Comment, you and any coauthors transfer copyright to the journal if your Comment is posted.
* = Required Field
Disclosure of Any Conflicts of Interest*
Indicate all relevant conflicts of interest of each author below, including all relevant financial interests, activities, and relationships within the past 3 years including, but not limited to, employment, affiliation, grants or funding, consultancies, honoraria or payment, speakers’ bureaus, stock ownership or options, expert testimony, royalties, donation of medical equipment, or patents planned, pending, or issued. If all authors have none, check "No potential conflicts or relevant financial interests" in the box below. Please also indicate any funding received in support of this work. The information will be posted with your response.
Some tools below are only available to our subscribers or users with an online account.
Download citation file:
Web of Science® Times Cited: 1
Customize your page view by dragging & repositioning the boxes below.
Users' Guides to the Medical Literature
Abdominal Aortic Aneurysm
The Rational Clinical Examination
Make the Diagnosis: Abdominal Aortic Aneurysm
All results at
Enter your username and email address. We'll send you a link to reset your password.
Enter your username and email address. We'll send instructions on how to reset your password to the email address we have on record.
Athens and Shibboleth are access management services that provide single sign-on to protected resources. They replace the multiple user names and passwords necessary to access subscription-based content with a single user name and password that can be entered once per session. It operates independently of a user's location or IP address. If your institution uses Athens or Shibboleth authentication, please contact your site administrator to receive your user name and password.