The importance of keeping in the loop about abdominal pain

A 59-year-old Italian woman presented to our emergency department with worsening crampy pelvic abdominal pain, accompanied by severe nausea and vomiting. She experienced constipation 24 hours after the onset of symptoms but denied having a fever or any urinary issues. Her medical history included an appendectomy and a hysterectomy performed 10 years prior. Upon examination, her abdomen was tender, and she rated her pain as severe (10/10). Point-of-care ultrasound revealed fluid-filled, dilated small bowel loops with increased parietal thickening and free fluid between bowel loops, along with a “caliber jump” observed between the swollen loops upstream and the collapsed loops downstream of the obstruction. All laboratory tests were within normal limits, including lactate levels. The patient was treated with intravenous morphine and crystalloids. A computed tomography (CT) scan of the abdomen was immediately performed afterward and showed the so called “bunch of grapes sign” (panel A, red circle) and multiple dilatated small bowel loops (panel B).