LAUSR

A 26-year-old woman was presented to the emergency department with acute abdomen—she complained about having abdominal pain and postprandial nausea, but was not able to vomit. The symptoms started previous day. Despite the asthenic habitus, her abdomen was extremely distended. Her anamnesis was suggestive for eating disorder, also she revealed that she had previously experienced similar attacks. She had taken no medication. On examination her abdomen was significantly distended, painful with guarding, signs of peritoneal irritation, absence of bowel sounds. Her laboratory tests were within normal limits, except for mildly elevated amylase level (4.04 ukat/L, normal value 0–1.67 ukat/L). Direct thoraco-abdominal X-ray image obtained in a standing position demonstrated dilatation of the stomach with airfluid level, an air fluid-level was present also in the right upper quadrant of the abdomen, probably in the first part of the duodenum. Abdominal ultrasound was limited; because of the pain, the patient did not tolerate the horizontal position, and no intraperitoneal fluid was observed. Due to the described condition and for further diagnostics and therapy she was admitted to our surgical department. Initial treatment included fluid resuscitation, analgesics. A nasogastric tube was inserted to decompress the stomach—immediately more than 5 L of gastric dilatation fluid (dark green–colored fluid) was discharged, with slight symptomatic improvement. As part of further evaluation, abdominopelvic computed tomography (CT) was performed. The results revealed a massive distended stomach filled with large amounts of solid and fluid content, reaching from the diaphragm down to the iliac bone and the pelvis; the dilated stomach caused compression to the intra-abdominal organs (also the D1 to D3 parts of the duodenum); the D4 part of the duodenum was occluded, and her intestinal loops were pressed toward the pelvis (Figs. 1, 2, and 3). The stomach was full with content, although the nasogastric tube was correctly inserted. She was treated by continuous aspiration and by using endoscopic fragmentation and removal of the food particles. In the first 2 days, she remained on parenteral nutrition, followed by gradually increased diet— initial regimen included fluids, later small amounts of solid food. Later, upon psychiatric consultation, anorexia nervosa was revealed. She was discharged home, supported by her family.