Figure 1. Plain abdominal X-ray: (A) Multiple air-fluid levels visible in the small bowel loop in in erect view ; (B)Prominent dilated small bowel loops seen in supine view
Ultrasonography of the abdomen and pelvis was unremarkable with minimal free fluid in the pelvis. Urgent Contrast Enhanced Computed Tomography (CECT) scan was performed which confirmed collection of fluid in the right iliac fossa, pelvis and along the anterior surface of the liver. It was however unremarkable and no specific findings were documented supportive of mesenteric ischemia. Despite aggressive fluid management, analgesics and intravenous antibiotics, the condition of the patient did not improve. Hence, the patient underwent emergent laparotomy. Intraoperatively, greenish fluid and gangrenous small bowel starting from 20 cm distal to the duodenojejunal flexure to 15 cm proximal from the Ileocolic junction was seen (Figure 2). Tissue decay with blackish discoloration of the intestine was found which is suggestive of AMI. Resection of the gangrenous segment of the bowel with double barrel loop ileostomy was performed.