Intermittent small bowel obstruction from rotational variation of the duodenum due to ligament of treitz takedown for an aortic jump graft

Abstract

A 43-year-old female with a history of polycystic liver disease presented for evaluation of chronic, intermittent nausea and vomiting, which began after orthotopic liver transplantation. The liver transplant was accompanied by the placement of an aortic jump graft due to thrombosis of the donor hepatic artery and a weak pulse in the recipient hepatic artery. On presentation, the physical examination was notable for abdominal distension and epigastric tenderness to palpation. Laboratory values were within normal limits, and esophagogastroduodenoscopy was normal. The patient subsequently underwent an upper gastrointestinal small bowel follow-through study. During the initial stages of the upper gastrointestinal study, the duodenum was found to remain within the right upper abdomen (Fig. 1). During the study, the patient vomited, and subsequent imaging demonstrated that the duodenum crossed the midline and assumed its expected position within the left upper abdomen, with the duodenal-jejunal junction at the level of the duodenal bulb (Fig. 2). Follow-up imaging then demonstrated the jejunal bowel loops to be within the left abdomen (Fig. 3).