Clinical presentation

A 22 year old man presented to the clinic with a history of chronic intermittent abdominal complaints. He reported postprandial colicky pain, nausea, and loud abdominal sounds since his youth. The severity of symptoms tempted the man to eat mainly in the evening because in school or at work the loud abdominal sounds attracted attention and he was embarrassed. He had undergone upper gastrointestinal surgery at the age of six years but he was not aware of the exact procedure. On clinical examination he showed a reduced nutritional status with a body mass index of 14 kg/m², the abdomen was tender, showed no resistance, but loud bowel sounds were apparent.

Question

What is the diagnostic clue on the transverse ultrasound scan through the upper abdomen (fig 1)?

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Figure 1

 Transverse ultrasound scan through the upper abdomen. A, aorta; SMV, superior mesenteric vein; SMA, superior mesenteric artery; VCI, vena cava inferior.

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