Clinical presentation

An 84 year old women presented with a six hour history of acute abdominal pain, coffee ground vomiting, and altered blood per rectum. Her past medical history included hypertension, atrial fibrillation, and arthritis. On examination she was afebrile, normotensive, but tachycardic. There was generalised abdominal tenderness and guarding with vague localisation towards the right lower quadrant. Rectal examination revealed fresh blood mixed with stool. Blood results were unremarkable. Plain radiographs suggested a degree of small bowel obstruction with no evidence of free air. The patient underwent intravenous contrast enhanced 16 detector multislice computed tomography (fig 1). The patient refused surgical exploration and thus was treated conservatively. She subsequently had multiple episodes of melaena and died 72 hours after admission.

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Figure 1

 Intravenous contrast enhanced 16 detector multislice computed tomography of the upper abdomen.

Question

What is the diagnosis?

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