A 70-year-old woman presents with central colicky abdominal pain, vomiting, and abdominal distension. She has had no previous surgery. AXR shows multiple distended small bowel loops with a 'coffee bean' sign pointing to the right iliac fossa. The MOST likely diagnosis is:

• A Sigmoid volvulus — the coffee bean sign in the pelvis indicates this
• B Adhesive small bowel obstruction from previous gynaecological surgery
• C Gallstone ileus with Rigler's triad on AXR
• D Caecal volvulus — the coffee bean sign represents the distended caecum rotated into the right iliac fossa ✓

Explanation

The coffee bean sign on AXR directed toward the right iliac fossa (or right upper quadrant) with distended small bowel represents caecal volvulus — the caecum and terminal ileum undergo axial twisting on the mesenteric axis. Sigmoid volvulus produces a coffee bean sign in the pelvis/left side pointing toward the right upper quadrant with the apex toward the right. Adhesive SBO is the commonest cause of SBO in those with prior surgery, but this patient has had none. Gallstone ileus shows Rigler's triad (pneumobilia + SBO + ectopic calcified gallstone).

Reference: Bailey & Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

Written and medically reviewed by the StethoPrep medical team.