History
A 21-year-old lady with a past history of developmental delay and mental retardation is admitted for coffee ground vomiting. She has had multiple readmissions for a similar problem. She has normal bowel motions and flatus. There is no other significant past medical history.
•Afebrile, pulse 72 bpm, BP 115/80mmHg, SaO2 98-100% on RA.
•Hydration is satisfactory.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•Her chest is clear on auscultation.
•Abdominal examination reveals a distended abdomen, but no frank peritoneal signs could be elicited. Bowel sounds are sluggish.
•No signs of oedema.
Investigations
•CBC:
–WBC 9.9 x 109/L;
–haemoglobin 13.1g/dL;
–platelets 289 x 109/L.
•Electrolytes are grossly normal.
•Bone profile is normal.
•Amylase 113 IU/L.
•pH 7.43.
•BE -2.
•sTSH 3.78mIU/L.
An abdominal X-ray is also performed (Figure 20.1).
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Please describe what you see
There are markedly dilated large bowel loops.
What is your differential diagnosis?
Mechanical:
•Large bowel intestinal obstruction.
•Colonic volvulus.
Non-mechanical:
•
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