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Image challenge: A fatal cause of small bowel obstruction

What caused nausea and nonbilious vomiting in a patient with multiple loops of distended proximal small bowel?

Gastroenterology clinical image challenge: A 76-year-old man presented to our clinic complaining of nausea and nonbilious vomiting for the past four months that had worsened over past three days. He noted a weight loss of more than 20 pounds over the past month associated with decreased appetite. He also complained of intermittent abdominal pain, which is diffuse and not related to food intake. He denied having any fever, chills, diarrhea or constipation. Past medical history was significant for hypertension, hyperlipidemia, diabetes mellitus, seizure disorder and blindness owing to glaucoma. Past surgical history was significant for cholecystectomy for acute cholecystitis and prostatectomy for prostate cancer. Vital signs were remarkable for elevated blood pressure at 153/103 mm Hg and elevated heart rate at 103 beats/minute. Physical examination showed the patient appeared cachectic. The abdomen was soft, nondistended and nontender. Guarding and rebound tenderness were not elicited.

Laboratory studies showed mild decrease in hemoglobin at 13.7 g/dL (normal, 14.0–18.0 g/dL). The total white blood cell count was normal at 7.63 K/μL (normal, 3.50–10.80 K/μL) with neutrophilia at 80.2% (normal, 40.0%–74.0%) and lymphopenia at 8.7% (normal, 19.0–48.0%). Comprehensive metabolic panels showed decreased sodium at 129 mmol/L (normal, 136–145 mmol/L) and decreased chloride at 83 mmol/L (normal, 98–107 mmol/L). The patient was then admitted for further evaluation. A nasogastric tube was placed and 1 L of bilious fluid was drained. Subsequently, the patient developed altered mental status and hypotension, his blood culture showed gram-negative bacteremia. Abdominal and pelvic contrast-enhanced computed tomography scans revealed multiple loops of distended proximal small bowel measuring up to 5.25 cm (figure), with a transition point seen within the anterior epigastrium (figure), consistent with a small bowel obstruction.

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