An abdominal x-ray reveals marked gaseous distention of the stomach, with a paucity of gas in the rest of the abdomen and a concern for pneumatosis in the left middle abdomen.

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Anteroposterior abdominal radiograph demonstrating a large amount of gastric air (dashed arrow), with a paucity of air in the lower abdomen and concern for pneumatosis in the left quadrant (solid arrows).

 

The patient receives an intravenous fluid bolus in the ED and is started on maintenance fluids. A formula feed is attempted but the patient promptly vomits and feeds are held pending further investigation.

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How does this additional information affect your differential diagnosis?

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Based on your differential diagnosis, which of the options below is likely to be the highest yield next diagnostic step? 

(A) Barium contrast enema

(B) Serum lipase

(C) Fluoroscopic upper GI study

(D) Abdominal ultrasound

(E) Arterial blood gas and co-oximetry