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Case Presentation

An 84-year-old white woman with a medical history of diverticulosis presented with a chief complaint of nausea, vomiting, and abdominal pain. The patient reported that her symptoms began 4 days earlier, with fatigue, followed by repeated episodes of nausea and vomiting of food (without blood) and severe pain that began in her lower back and then radiated to her bilateral lower quadrants. She denied any gastrointestinal bleeding or diarrhea. She subsequently developed “hot and cold waves,” sweats, and shakes, at which point she called emergency medical services. The patient was taken to an outside hospital, where abdominal films showed dilated loops of large bowel in the left lower quadrant (not shown). She underwent a colonoscopy (not shown) that showed no volvulus and extensive diverticulosis, but the colonoscope was unable to pass to the right colon. She was sent to the Hospital of the University of Pennsylvania (HUP) 3 days later.

Further Work-up

On admission to HUP, the patient stated that she had been feeling better throughout the day (of admission) and reported a 50% improvement in her nausea and near resolution of her abdominal pain. Physical exam revealed a temperature of 97.8° F, blood pressure of 154/72, pulse rate of 78 beats per minute, and oxygen saturation of 94% on room air. Her lungs were clear and her heart showed regular rhythm with an S4. The abdomen showed mild diffuse tenderness (greater in the upper than lower abdomen), no rebound, and no guarding. Results of complete blood count and serum chemistries were unremarkable. However, in the evening of the day that the patient was admitted to hospital, her abdominal pain worsened. Physical examination showed that she had become much more distended. She underwent abdominal radiography followed by a barium enema study (Figures 1 and 2).

1. Based on the clinical findings and results of imaging studies, what is your diagnosis?