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June 17, 2019

Image challenge: Small bowel necrosis after colonoscopy

What caused a 73-year-old woman lower abdominal pain and obstipation 12 hours after a colonoscopy?

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Gastroenterology clinical image challenge: A 73-year-old woman underwent surveillance colonoscopy for a history of colon adenomas. The colonoscopy was uncomplicated and remarkable for three small rectosigmoid polyps that were resected with cold biopsy forceps. The patient was discharged home, and approximately 12 hours later she had the acute onset of lower abdominal pain and obstipation. She presented to the emergency department and on physical examination there was mild abdominal distension with tympany and lower abdominal tenderness to deep palpation. Computed tomography (CT) scans of the abdomen and pelvis showed mildly dilated small bowel loops consistent with ileus. She was admitted to the surgery service and a nasogastric tube was placed to suction with bilious output. Later that night, she developed tachycardia and tachypnea. Physical examination showed worsening abdominal distension and tenderness. Blood tests revealed new leukocytosis, lactic acidemia and hypoalbuminemia. Repeat CT scans of the abdomen and pelvis showed persistently dilated small bowel loops and new pneumatosis intestinalis with pneumoperitoneum (figure). She underwent emergent exploratory laparotomy that revealed small bowel necrosis (figure).

What was the cause of her small bowel obstruction and necrosis?

To find out the diagnosis, read the full case in Gastroenterology.

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