Bouliaris et al. Journal of Medical Case Reports 2011, 5:507 http://www.jmedicalcasereports.com/content/5/1/507 hours and two episodes of vomiting. On physical exami- nation his abdomen was mildly distended with a diffuse tenderness on the hypogastrium. There was no rebound or guarding and palpation did not reveal any abdominal masses. His bowel sounds were increased. His blood tests were unremarkable. Plain abdominal X-rays revealed a dilated small bowel loop consistent with intestinal obstruction. He was initially treated with intra- venous fluid replacement and nasogastric tube but his symptoms did not resolved. An enhanced-abdominal CT scan showed a small bowel loop with a thickened wall and narrow lumen with proximal bowel dilation. There was also increased density of the adjacent mesenteric fat (Figure 1). Bearing in mind the episodes of diarrhea as well as the loss of weight, we included Crohn’s disease in our differential diagnosis. Further investigation with colonoscopy and a barium enema did not reveal any pathology. In view of his continuing symptoms and the radiological evidence of a small bowel obstruction, a laparoscopic exploration was carried out. Due to multi- ple adhesions though, we had to convert our plan to a laparotomy. During the operation we found a thickened segment of ileum in his pelvis adherent to his bladder and the apex of the sigmoid loop. There was a stricture in his ileum at this point, and an ileosigmoid fistula was present (Figure 2). The abnormal ileal loop was mobi- lized from his bladder and the sigmoid and resected, with restoration of intestinal continuity by primary side- to-side ileoileal anastomosis. The sigmoid fistula point was closed with seromucosal sutures. Histological exam- ination of the resected specimen showed a mixed acute and chronic inflammatory process with hypertrophy of the muscularis externa. There was no evidence of Crohn’s disease or malignancy. Our patient had an Figure 1 Preoperative abdominal CT scan. Shows a small bowel loop with a thickened wall and narrow lumen with proximal bowel dilation (black arrow). Increased density of the adjacent mesenteric fat (white arrow), as well the normal distal ileum (head arrow) can also be seen. Page 2 of 3 Figure 2 Intraoperative image. (A) Thickened proximal ileum; (B) normal distal ileum; (C) fistula point in sigmoid; (D) strictured ileum segment. uneventful recovery and was discharged from hospital nine days later. At follow-up eight months later, he was symptom free and had regained weight. Discussion Traumatic small bowel stricture and delayed small bowel obstruction secondary to BAT is a rare clinical entity. It is the result of local ischemia of the bowel wall and its subse- quent healing with fibrosis and stricture, which causes the delayed onset of symptoms [12]. This local bowel ischemia can be caused by an injury to the mesentery, which impairs the blood supply to the bowel resulting in a steno- tic segment, or a trauma which causes sufficient damage to the small bowel to result in hemorrhagic mucosal infarction or subclinical bowel perforation [8,9,12,13]. Patients suffering from post-traumatic small bowel obstruction usually present with intermittent abdominal pain and vomiting [9]. The interval between trauma and the onset of symptoms ranges from 13 days to 18 years, although the majority of patients experience symptoms within four to eight weeks of the initial trauma [9]. When small bowel obstruction is suspected, the investigation of choice is a small bowel contrast study or a contrast- enhanced CT [9,11,14]. Laparotomy and resection of the stenosed segment with primary anastomosis is the treat- ment of choice [9]. The presence of free intraperitoneal fluid in the abdo- men without any evidence of solid organ injury is indeed an intriguing diagnostic challenge. Concerning the role of CT, it is unclear if it can provide a solid and conclusive answer as to whether surgery or close obser- vation is best. Although CT exhibits very high sensitivity and specificity in detecting most solid organ injuries, it can still miss up to 15% of small bowel and mesenteric injuries [15-17]. We believe that laparotomy is not