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Miss M, a 23 year old international student, presented with an eight week history of nausea, biliary vomiting, constipation, and abdominal pain with hyperactive bowel sounds. On examination, the only abnormality was some tenderness in the right upper quadrant and the epigastric area. She is a very sociable young woman who liked to party but did not admit to drinking in excess, except on one night, approximately three months previously, when she crashed her car against a fence and sustained a fracture of an L5 transverse process. She was kept under observation on this occasion but was finally sent home.
Plain abdominal x rays revealed several prominent loops of proximal small bowel but no other changes. The gastrografin swallow was normal but computerised tomography showed an area of thickening in the wall of the proximal jejunum.
With the diagnosis of small bowel obstruction she underwent laparotomy (fig 1).
What abnormalities are apparent? What is your diagnosis? What are the pathogenetic mechanisms of this condition?
See page 1050 for answer
This case is submitted by:
Robin Spiller, Editor
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