the case.
a 64 year old female presents to your Emergency Department at midnight with acute severe abdominal pain.
She has a past medical history of rectal cancer which had been treated with resection & a defunctioning colostomy. This had been successfully reversed 4 years ago.
Our patient reports three days of colicky abdominal pain & reduced bowel motions, however developed sudden, severe abdominal pain at precisely 8pm tonight & just ‘cannot get comfortable now’ !! There is associated nausea and vomiting (without haematemesis) as well as severe pain in her right shoulder. Despite 20mg of intravenous morphine, she is crying in pain & unable to settle in the bed.
On examination; she has frank peritonism & a palpable (exquisitely tender) hernia in her right lower quadrant, adjacent to an old surgical scar.
Amongst the usual work-up (demonstrating acute kidney injury & a white count > 18,000) she undergoes plain x-rays of the abdomen….
Supine AXR with an unusual pattern of extraluminal gas extending from right psoas muscle, along the vertebral column involving the perisplenic & perinephric spaces; suggestive of retroperitoneal perforation (pneumoretroperitoneum).
Erect AXR with an unusual pattern of free-gas. Localised gaseous bowel distension (right side) with an air-fluid level.
Given the above findings, we arrange for a CT of her abdomen. IV contrast is withheld given the new renal impairment.
httpv://www.youtube.com/watch?v=4abNgrfq7LE
A right incisional hernia containing distended loops of ascending & proximal transverse colon resulting in a closed-loop obstruction of the hepatic flexure. Extensive extra-peritoneal gas, consistent with perforation of the obstructed hepatic flexure.
Retroperitoneal perforation.
Results in pneumoretroperitoneum – the presence of gas within the retroperitoneal space.
Typically the air outlines structures like the kidneys, psoas muscles and retroperitoneal portions of the bowel
The hallmark of this is the “veiled kidney sign”.
“Veiled kidney sign”
Recall the structures that reside in the retroperitoneal space.
Causes of pneumoperitoneum.
- Duodenum.
- Peptic ulcer disease
- Blunt abdominal trauma / duodenal haematoma ← Click here for a case from The Trauma Professional’s Blog.
- Penetrating abdominal trauma
- Complication of ERCP or endoscopy
- Rectum.
- Malignancy
- Foreign body insertion
- Pelvic trauma
- Complication of endoscopy
- Contrast enema
- Colon (ascending & descending).
- Diverticulitis
- Appendicitis
- Ischaemic colitis
- Malignancy
- Complication of endoscopy / polypectomy.
- Genitourinary.
- Post-operative residual air
- Infective
- Spontaneous (renal transplant / immunosuppressed)
With the above diagnosis; she receives ongoing analgesia, volume replacement, electrolyte correction, nasogastric tube & in-dwelling catheter.
At sunrise she is taken to theatres for a laparotomy which reveals that her ascending colon & part of the hepatic flexure was incarcerated in the incisional hernia with a focal area of necrosis (the point of perforation). She undergoes a right hemicolectomy.
There is a rocky post-operative course with multiple sub-diaphragmatic abscesses requiring drainage however she is finally discharged 26 days after her initial presentation to ED.
- Yagan N, Auh YH, Fisher A. Extension of air into the right perirenal space after duodenal perforation: CT findings.Radiology. 2009 Mar;250(3):740-8
- Wang, HP & Su, WC. Veiled Right Kidney Sign in a Patient with Valentino’s Syndrome. N Engl J Med 2006; 354:e9
- Yildirim, M et al. Retroperitoneal perforation of the rectum during double-contrast barium-enema examination: a life-threatening complication. Radiol Oncol 2009; 43(1): 26-9.
- Pneumoretroperitoneum @ Radiopaedia.org
I see a lot of patients with digestive troubles, particularly with history of abdominal surgery, and cancer. Not so easy to have a precise diagnosis just with clinical exam and abdominal X-ray. Always fear to have a bowel obstruction, more severe than we thought.
In France we have recommandations to avoid abdominal X-ray, even in acute abdomen. But in the middle of the night, sometimes I don’t have a better exam as fast as I want.
After in the day, we do a lot of CT scan before admission in surgery or GI.
Anyway, thanks it was a very interesting case.
Great case Chris. Thanks for the timely reminder
Yo,
Couple of things..just my thoughts on dx and tx of this pt
1. All u need to dx this pt is the xray and P.E. Do NOT waste your time with CTscan, especially when the oral contrast is just going to make the pt vomit and possibly leak into her colemic cavity. This is merely delaying the dx and hurting the pt badly as further delay of definitive care of pts septic shock (as this pt is likely in given ber AKI), increase morbidity and mortality dramatically. Definitive diagnosis is made in the operating room.
2. Treatment
1. Large bore access 9fr introducer IJ (or 16 14G pivs) and poss aline given pts HD status and lactate
2. Copious IV resuscitation LR or NS based on chems..DRAW ABG and lactate stat!!
3. BROAD spectrum IV abx
4. NG tube to LCWS
5. Call surgeon ASAP as this is a surgical urgent case and CANNOT wait til morning.