Picture Quiz: a comma in the colon.(education)

Case history

You are on a surgical firm, when a call comes through from a local general practitioner regarding one of his patients whom he is sending urgently to the emergency department by ambulance. The patient is a 43 year old woman, who presented this morning with sudden onset of severe abdominal pain. The pain is diffuse, constant in nature, and associated with nausea and vomiting. Initially, the patient had diarrhoea, but has now developed complete constipation. On examination she has pyrexia, tachycardia, and a rigid abdomen. The white cell count and inflammatory markers are raised. When the patient was 3 months old she had an operation for intussusception. Fifteen years ago she had a similar episode and at laparotomy, bowel obstruction secondary to adhesions was diagnosed--approximately 20 cm of small bowel …