Differential Diagnosis

• Single most likely diagnosis:
  • Incarcerated small bowel obstruction due to left stomal hernia: The patient's symptoms of nausea, vomiting, abdominal distension, and no stoma output, combined with the CT findings of a left stomal hernia with dilated small bowel loops and a transition point within the hernia, strongly suggest an incarcerated small bowel obstruction. The presence of free fluid and haziness of the mesentery within the hernial sac further supports this diagnosis.
• Other Likely diagnoses:
  • Dehydration: The patient's symptoms of dark urine and increased frequency of urine, along with the lack of stoma output, suggest dehydration, which may be contributing to her overall clinical presentation.
  • Kidney stones: The presence of kidney stones, particularly the 14.5 mm stone in the left kidney, could be causing the patient's symptoms of nausea, vomiting, and abdominal distension, although the CT findings suggest that the small bowel obstruction is the more pressing issue.
  • Adhesions: The CT findings of haziness of the mesentery and free fluid within the hernial sac could also be due to adhesions, which are a common complication in patients with a history of abdominal surgery.
• Do Not Miss (ddxs that may not be likely, but would be deadly if missed.):
  • Bowel ischemia: If the small bowel obstruction is not promptly relieved, bowel ischemia could occur, leading to necrosis and potentially life-threatening complications.
  • Sepsis: The presence of free fluid and haziness of the mesentery within the hernial sac could indicate the start of an infectious process, and sepsis is a potentially deadly complication that must be considered.
  • Uremia: The patient's symptoms of dark urine and increased frequency of urine, combined with the presence of kidney stones, could indicate uremia, which is a life-threatening complication of renal failure.
• Rare diagnoses:
  • Internal hernia: Although the CT findings suggest a left stomal hernia, an internal hernia is a rare possibility that could be causing the patient's symptoms.
  • Intussusception: The patient's symptoms of abdominal distension and lack of stoma output could be due to intussusception, although this is a rare diagnosis in adults.

Management

The patient should be managed with prompt surgical consultation for relief of the small bowel obstruction. IV fluids should be administered to correct dehydration, and the patient should be closely monitored for signs of bowel ischemia or sepsis. The kidney stones should be addressed, but this is likely a secondary concern at this time. The patient's diabetes should also be managed to prevent any complications.