Case 6

I am presented with non-contrast and post-contrast CT series of the abdomen and pelvis post administration of oral contrast media to opacify the small bowel lumen. There is marked small bowel dilatation, down to a loop of ileum in the pelvis – this loop of bowel has a C shape configuration and demonstrates two transition points, with beak like tapering of the dilated loop proximal to it. These features indicate a closed loop obstruction.

Mesenteric vessels appear to stretch and converge towards a focus where the transition points are found. The bowel loop in question shows thickened walls and surrounding fluid, which indicates strangulation and ischaemia of the closed loop.

The findings represent internal herniation of a small bowel loop, which has led to a closed loop obstruction causing strangulation and ischaemia of the loop.  

The differential diagnosis would be small bowel volvulus – however there isn’t obvious swirling / rotation of the mesenteric vessels.

The patient is post hysterectomy, which suggests that this post surgical / trans-mesenteric hernia. 

There is a nasogastric tube in situ which appears kinked. There is also a Foley catheter in situ in the urinary bladder.

There is a minimal right sided pleural effusion.

I would urgently contact the referring physician and recommend surgical consultation. Urgent operative management will be required.