A 59-year-old woman with history of pylorus-preserving pancreaticoduodenectomy for pancreatic hamartoma and partial colectomy for sigmoid volvulus presented with nausea, vomiting, constipation, sharp constant mid-abdominal pain, and abdominal distension for 2 days. She had tachycardia and diffuse mild abdominal tenderness with hypoactive bowel sounds. Lab revealed WBC of 14.1K/μL and creatinine of 2.62 mg/dL. Nasogastric tube placement yielded 4,000 mL of bilious fluid in the first hour. Computed tomography (CT) scan of the abdomen with oral contrast demonstrated a massively distended stomach extending into the pelvis, measuring 15 cm transversely, 14 cm antero-posteriorly, and 35 cm craniocaudally (Figure 1). Small bowel follow-through study performed 48 hours later did not show any obstructive pathology. Patient responded to conservative management and was discharged home.
Six weeks later, the patient readmitted with similar presentation. CT scan showed partial bowel obstruction in the mid-anterior abdomen, possibly involving multiple segments of small bowel and a portion of colon. As she did not respond to 10 days of conservative management, laparotomy was performed, which revealed small bowel closed loop obstruction due to internal hernia, obstructing the biliary limb of Whipple procedure adjacent to the gastrojejunostomy. Release of small bowel obstruction was performed, followed by over-sewing of the biliary limb serosa and closure of the internal hernia. The patient was discharged on post-operative day 7.
Figure 1. Massive gastric distention shown on CT.
Author contributions: P. Patel designed the case report, collected the information, and is the guarantor of the article. P. Patel, N. Patel, and A. Atia jointly interpreted the information and wrote the article. R. Murthy and M. Young supervised and edited the article. All authors discussed the case and commented on the article at all stages.
Financial disclosure: The authors have no relevant financial relationships to disclose for this article.
Correspondence: Pranav Patel, MD, ETSU Quillen College of Medicine, 1008 Quality Cir #71, Johnson City, TN 37615 (firstname.lastname@example.org).
Received: July 18, 2013; Accepted: August 30, 2013
© 2013 Patel et al. This work is licensed under a Creative Commons Attribution-NonCommercial-NoDerivs 3.0 Unported License. To view a copy of this license, visit http://creativecommons.org/licenses/by-nc-nd/3.0.