Massive Gastric Dilatation Secondary to Internal Hernia Obstructing the Biliary Intestinal Limb of Whipple Procedure

A 59-year-old woman with history of pylorus-preserving pancreaticoduodenectomy for pancreatic hamartoma and partial colectomy for sigmoid volvulus presented with nausea, vomiting, constipation, sharp constant midabdominal pain, and abdominal distension for 2 days. She had tachycardia and diffuse mild abdominal tenderness with hypoactive bowel sounds. Lab revealed WBC of 14.1K/μL and creatinine of 2.62 mg/dL. Nasogastric tube placement yielded 4,000 mL of bilious fluid in the first hour. Computed tomography (CT) scan of the abdomen with oral contrast demonstrated a massively distended stomach extending into the pelvis, measuring 15 cm transversely, 14 cm antero-posteriorly, and 35 cm craniocaudally (Figure 1). Small bowel follow-through study performed 48 hours later did not show any obstructive pathology. Patient responded to conservative management and was discharged home.