Worsening abdominal pain,...

A 42-year-old male presented with worsening abdominal pain, nausea and vomiting for three days to the hospital. On admission, his history was remarkable for four similar prior episodes. He denied constipation, obstipation or associated hematemesis, fevers, chills or urinary symptoms. During the first episode, he was with peptic ulcer disease and was managed with omeprazole intermittently. His past medical and surgical history was nonremarkable. He had no allergies, and he denied alcohol intake or tobacco use. 

Abdominal examination revealed mild distension with generalized guarding and marked rebound tenderness in the epigastrium. There were no palpable masses, and bowel sounds were absent. However, abdominal ultrasonography revealed free fluid throughout the abdomen and pelvis. The peritoneum was accessed via a vertical midline incision. The anterior stomach, duodenum, gallbladder, liver, small bowel, colon and appendix were normal. Palpation through the stomach and transverse mesocolon noted a firm midline mass-like structure. In addition, as shown in the figure, there were multiple sub-centimetre white nodules on the transverse mesocolon. There was marked inflammation found between the stomach, transverse mesocolon and pancreas.