Rough Game of Golf

A 26 year-old morbidly obese otherwise healthy male presents with chief complaint of constipation. The patient states he has been unable to have a bowel movement for the past 5 days nor has been passing gas. He reports taking a couple over-the-counter laxatives as well as Miralax prescribed to him by an urgent care provider 2 days ago but still has not been able to have a bowel movement. He also reports self-induced vomiting 3 days ago in order to "get relief." He denies a history of prior abdominal surgery or prior constipation. 

His other symptoms include mild right upper quadrant pain and worsening shortness of breath with exertion that was especially noticeable during an 18-hole game of golf a week and a half ago. On further questioning he admits that he can no longer walk up a flight of stairs or tolerate lying flat for prolonged periods of time. He denies having any chest pain. He denies fever, chills, cough, swelling, weight changes, or recent travel. 

EXAM

Vital signs: T 37.2 | BP 124/73 | P 105 | R 20 | SaO2 100% on room air 

On exam the patient is a young morbidly obese Caucasian male with moderate diaphoresis of the face and neck and mild tachypnea. Hearts sounds are slightly muffled with no murmurs, gallops or rubs detected. Breaths sounds are clear bilaterally. Abdomen is soft and nontender. Extremities are cool with 1+ peripheral pulses and no evidence of peripheral edema. 

DIAGNOSTIC TESTS

An abdominal series was obtained and is shown below: 

What is the diagnosis?

How would you manage this patient? 

Please leave a comment below and share your thoughts. 

The diagnosis for this case will be posted in approximately 1 week.