Gastroenterology clinical image challenge: An 82-year-old man was admitted for urgent coronary artery bypass and concurrent mitral valve repair. Intraoperatively, he underwent cardiopulmonary bypass, epicardial pacing and placement of two anterior mediastinal and one pleural chest tubes. After a relatively unremarkable initial postoperative course and non-narcotic pain control, concern for ileus developed on postoperative day four. A nasogastric tube was placed out of concern for worsening somnolence, nausea and the inability to safely tolerate oral intake. The patient had been passing flatus but had yet to have a bowel movement since the operation. Physical examination at the time was notable for a soft abdomen with diffuse tenderness and voluntary guarding. Subsequent plain film imaging to confirm nasogastric tube placement (figure) and follow-up computed tomography imaging are shown (figure).
What is the diagnosis?
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