A 70-year-old man presents to the emergency department (ED) with generalized abdominal pain and distention. The distention has increased progressively over the last 4 days, with a substantial increase today. His mental status has progressively deteriorated, and he cannot provide additional information regarding the onset, course, and character of the pain. The patient’s family states that he has not had a bowel movement in 2 days and has never experienced similar symptoms. The patient is a known hypertensive and has been on oral medication for his blood pressure for the past 18 years. He does not have any history of diabetes, myocardial infarction, or stroke. There is no past history of any abdominal surgery. There is no history of travel, the patient is a nonsmoker, and he does not consume alcohol.
On physical examination, the patient is an obese (approximately 242.5 lb [110 kg]), elderly male, who is obtunded. He has a patent airway, bilateral rales, and diminished air entry into both lung bases, normal S1 and S2 heart sounds, pallor, poor capillary refill, and a weak, rapid radial pulse. His heart rate is 124 beats per minute. The patient is febrile, with a temperature of 102.0°F (38.9°C). His blood pressure is 85/65 mm Hg, respiratory rate is 26 breaths/min, and a partial pressure of carbon dioxide (Pa co2) is 52% while breathing room air. The patient’s abdomen is grossly distended and hyper-resonant, particularly above the umbilicus. Bowel sounds are totally absent; digital rectal examination reveals hard stools in the rectum. The patient is resuscitated in the ED using an intravenous infusion of lactated Ringer solution. Orotracheal intubation is performed and mechanical ventilation maintained. Intravenous antibiotics are started and a surgical consultation ordered, and then the patient is transported to the intensive care unit.
Laboratory results reveal a white blood cell count of 22,500 cells/mm3 (normal range, 4,000-11,000 cells/mm3), with 82% neutrophils (normal range, 40%-75%). The serum hemoglobin is 9.2 g/dL (normal range, 13.5-18 g/dL), and the hematocrit is 27.5% (normal range, 40%-54%). The serum alanine aminotransferase (ALT) is 78 U/L (normal range, 5-40 U/L), serum bilirubin is 2.3 mg/dL (normal range, 0.2-1.2 mg/dL), and serum C-reactive protein is 28 mg/dL (normal value, < 1.2 mg/dL). Serum creatinine is 4.8 mg/dL (normal range, 0.6-1.4 mg/dL), and serum urea is 79 mg/dL (normal range, 17-50 mg/dL). The plain chest radiograph shows a large air-filled bowel loop in the left hemithorax, with displacement of the mediastinum towards the right side (Figure 1). Supine abdominal x-ray reveals distended small and large bowel loops (Figure 2). A CT scan of the abdomen using both oral and intravenous contrast shows eventration of the left hemidiaphragm and a small right inguinal hernia with a gas shadow amongst its contents (Figure 3). It also demonstrates thickening of the bowel wall and omentum in addition to multiple abscesses between the bowel loops and within the pelvis. The appendix cannot be visualized in the right iliac fossa and there is no evidence of mesenteric vascular occlusion.
What is the most likely diagnosis?
Hint: Review the findings of the CT scan.
Small bowel ischemia with peritonitis
Diaphragmatic hernia
Sigmoid volvulus
Complicated inguinal hernia with the appendix inside the hernial sac (Amyand’s hernia)
