Description

An 81 year old woman presented with a three month history of post-prandial lower abdominal discomfort, vomiting and diarrhoea, with worsening of symptoms in the last week. On examination there were no significant findings and abdominal xray revealed prominent but un-dilated bowel loops. Bloods showed a white cell count of 12.3, CRP 16 and stool cultures were negative.

Co-morbidities include Chronic Obstructive Pulmonary Disease, hypertension, atrial fibrillation, severe mitral regurgitation, chronic kidney disease (CKD3), diverticular disease and angiodysplasia of the stomach. She had also had a common bile duct stricture which had required a biliary stent and developed bowel obstruction secondary to adhesions post severe cholecystitis.

An initial diagnosis of recurrent adhesions secondary to the previous cholecystitis was made. The patients symptoms appeared to abate with a soft diet. A CT scan of the abdomen was performed (Figure 1).

A trial of NG feeding was started to meet calorific needs. However the patients symptoms recurred and she suffered a marked deterioration with severe abdominal pain and hypomagnesaemia two weeks into the admission. A repeat CT scan of the abdomen and pelvis with IV contrast was performed (Figures 2-4).

Questions
1. What feature is seen in Figure 1?
2. What does image 2 depict what is the differential now?
3. What does image 3 depict does this confirm the diagnosis?
4. How might a lung window (Figure 4) help make a diagnosis in the abdomen?