A 41 year old shop assistant was admitted with a seven week history of colicky lower abdominal pain associated with alternating constipation and diarrhoea. In the preceding three weeks, she had experienced night sweats and had lost 5 kg in weight. The patient was not taking any regular medication apart from steroid inhalers for mild asthma. Her periods were regular with no abnormal vaginal bleeding. She had recently developed a creamy white vaginal discharge, which had not been evaluated. The last menstrual period was three weeks before admission but a recent pregnancy test was negative. The obstetric history was gravida 5, para 3. An intrauterine contraceptive device (IUCD) had been inserted five years before.

Examination revealed a thin, emaciated women distressed by pain. She was afebrile and the vital signs were within normal limits. Mild suprapubic tenderness was noted on palpation. No organomegaly was discernable. Vaginal and rectal examination were normal. The laboratory findings were as follows: haemoglobin 111 g/l, white cell count 8.8 × 10⁹/l (85% neutrophils), and platelet count 547 × 10⁹/l. The biochemical profile was normal apart from mild hypokalaemia (potassium 3.1 mmol/l) and hypoalbuminaemia (albumin 31 g/l). Dipstick urine examination showed 3+ proteinuria and moderate leucocytes but several mid-stream urine cultures showed no growth. Vaginal smear examination revealed no abnormality. Multiple blood cultures were sterile. Plain abdominal radiography showed multiple fluid levels and dilated bowel loops suggestive of large bowel obstruction. Abdominal computed tomography (fig 1) and a barium enema examination (fig 2) were performed.

• Download figure
• Open in new tab
• Download powerpoint

Figure 1

Abdominal computed tomogram.

• Download figure
• Open in new tab
• Download powerpoint

Figure 2

Barium enema.