Acute Abdominal Pain

A 61-year-old man with a history of hypertension, diabetes, peripheral vascular disease, and congestive heart failure presents to the Emergency Department with left lower-extremity pain at rest and with a nonhealing ulcer of the left foot. The patient is admitted to the hospital for treatment of the ulcer and for a workup of his peripheral vascular disease.

Plain radiographs of the patient’s left foot and left lower leg show evidence of osteomyelitis of the distal first phalanx and distal tibia. After general and vascular surgeons evaluate him, they decide to proceed with a below-the-knee amputation on the left side. On postoperative day 2, the patient reports having severe midepigastric abdominal pain, as well as nausea, vomiting, and diarrhea, with no hematemesis or hematochezia.

On physical examination, the patient is afebrile but hypotensive, with a blood pressure of 88/54 mm Hg. He has slight tachycardia at a rate of 120 bpm. His oxygen saturation while breathing room air is 90%. His abdomen is distended, with diffuse rebound tenderness. Hypoactive bowel sounds are auscultated. The rest of his physical findings, including the condition of his postoperative wounds, are unremarkable. Laboratory results, including CBC and electrolyte levels, are within normal limits.

Plain radiographs of the abdomen are obtained (see Image 1), followed by contrast-enhanced CT scans of the abdomen and pelvis (see Images 2-3).

What is the diagnosis?

What is the diagnosis?
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Pay particular attention to the pattern of bowel gas and the solid organs.