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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.

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