Case of the Month July 2015

Submitted by Yaniv Raphael, MD, and Thomas J. Learch, MD .

A 15-year-old female visiting from South America presented to the Emergency Department with 5-day onset of intractable nausea, bilious emesis, and inability to tolerate PO intake. These symptoms were not associated with fever, diarrhea, dysuria, or hematemesis. No sick contacts are identified, and immunizations are up to date. Otherwise, the past medical and family histories were unremarkable. Vital signs were within normal range, and the physical examination was unremarkable. The laboratory data were within normal limits. Given the acuity of the symptoms, a contrast-enhanced CT of the abdomen/pelvis was ordered.

The study demonstrated marked distention of the stomach and the first through third portions of the duodenum with an abrupt transition to collapsed bowel just proximal to the fourth segment of the duodenum, at the level of the superior mesenteric artery (Images 1, 2, 3 and 4). The aorto-mesenteric angle was narrowed at 14 degrees (Image 5). The aorto-mesenteric distance was also diminished at 4-6 mm (Image 6). Otherwise, no mesenteric or retroperitoneal lymphadenopathy was noted. The appendix is unremarkable.

For larger images, please click on Rafael1 , Rafael2 , Rafael3 , Rafael4 , Rafael5 and Rafael6 .


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