QUESTION

A 44 year old woman was admitted with a two week history of colicky abdominal pain, vomiting, and constipation. Past medical history included Ehlers Danlos syndrome type IV with a history of spontaneous retroperitoneal haemorrhage treated conservatively. She was also known to have large uterine leiomyomas for which she was on hormonal therapy and was awaiting a hysterectomy.

On examination she had abdominal distension with generalised vague tenderness and some suprapubic fullness. Digital rectal examination revealed an empty rectum with a large pelvic mass bimanually palpable anteriorly.

Chest x ray was normal but supine abdominal x ray revealed faeces filled distended loops of large bowel with minimal air in the rectum. Routine blood tests were within normal limits. She was initially treated conservatively with laxatives and enemas which did not improve her symptoms. On the fourth day of admission she developed severe colicky abdominal pain, persistent vomiting, gross abdominal distension, and obstipation.

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