Image of the Month—Interactive Quiz

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

Figure 2.
Computed tomographic scan of the abdomen.

John Kubasiak, BA; John Linn, MD; Marie Crandall, MD, MPH

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 x10 ⁹/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 1and Figure 2). Fluid resuscitation was initiated.

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.

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