XRay Vision: Belly Pain Answer

Great job, Drs. Liang and Reisman. But the winner is…. Dr. Liang for providing a more thorough reading.

The CXR is read as pneumoperitoneum/free air under the diaphragm.

Differential diagnoses:

perforated viscus – perforated duodenal ulcer, perforated peptic ulcer, ruptured diverticulum

Toxic megacolon

Surgery (after laparotomy)

Peritoneal dialysis

This patient was diagnosed with perforated duodenal ulcer. Surgery was immediately consulted, and patient was taken to the OR for diagnostic and therapeutic ex-lap.

Perforation:

Clinical presentation: abrupt onset of severe epigastric pain as duodenal content is spilled into the peritoneal cavity. Followed by development of chemical and then bacterial peritonitis. NOTE: elderly patients may not have dramatic pain or impressive peritoneal findings.

Management:

Get appropriate lab test: cbc, type and screen, lipase, coagulation studies. Place two large bore IVs. Oxygen administration. NG tube should be inserted and place on suction. An acute abdominal series should be obtained. Administer broad-spectrum antibiotics. Surgery consult should be promptly obtained. In some cases nonsurgical therapy has been successful, but operative intervention is the standard.

By Dr. Joyce Wang

References:

Tintinalli’s Emergency Medicine: A comprehensive Study Guide

Emedicine Pneumoperitoneum Imaging: http://emedicine.medscape.com/article/372053-overview

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