Case 13

48 yo F presents w/ sudden onset abdominal pain. Pain has been constant since yesterday w/ no known precipitating factors. Symptoms are associated w/ left-sided chest pain, SOB, left arm numbness and right-sided lower back pain. Pt reports no change in appetite, last BM the same morning. She has seen blood in toilet bowl intermittently 2x per week. Pt also complains of abdominal distention x 1 week. Denies any nausea, vomiting, fevers, chills, dysuria or other associated symptoms.


CARDIOVASCULAR: (+) chest pain, (-) palpitations
GASTROINTESTINAL: (+) pain, (+) abdominal distension; (+) BM; (-) N/V
MUSCULOSKELETAL: (+) back pain


GI/ABDOMEN: Soft; (+) tenderness in all 4 quadrants; (+) guarding in all 4 quadrants; (+) distension w/ increased distension after PO contrast; (+) increased BS. Stool guiaic negative. (+) external hemorrhoids.
MUSCULOSKELETAL/EXTREMITIES: Normal ROM of all 4 extremities. (+) reproducible on palpation to left anterior chest wall and on deep inspiration. (+) tenderness on palpation of left lower back area. No CVA tenderness.

1. What anatomical structure are we looking at in the image below? What are A and B referring to?  Is there any pathology present?

2. What abnormality is seen here?  What could it represent?