Tuesday, July 12, 2005

Free Air isn't Cheap Either......
Continuing with the free air theme I present this case from my just completed weekend on call.
Elderly gentleman with a long history of "stomach problems". He has been admitted several times in the past with obstipation. Colonoscopy has been attempted in the past but the scope kept "coiling up" in his sigmoid colon. He presented to the hospital with increasing abdominal pain and distension which according to his family physician is how he usually presents with his obstipation. On exam he was afebrile and did not appear ill. His abdomen was distended and had mild diffuse tenderness. His WBC count was mildly elevated but he did not have a left shift. A not too impressive set of facts until I saw this:

The yellow lines indicate the diaphragm with air underneath it.
So we have what appears to be a perforated viscus.

Most likely a perforated ulcer or a portion of colon. Given his history I am inclined to believe the latter.
So what to do? The patient's physical exam and lab workup is not as impressive as that xray. But given his age he may not manifest a leukocytosis or have guarding or rebound on physical exam. On one hand he would be at very high risk for postoperative complications and prolonged vent dependence, something neither he nor his family want. If it was a colonic perforation the probability of colostomy was close to 100 percent and given his age and medical problems would likely be a permanent one. Non-operative treatment with bowel rest and antibiotics could also be tried. But the patients at most risk for surgery are the same ones that would not tolerate decompensation during non-operative therapy. After extensive discussions with his family and primary physician the decision was made to proceed to the operating room.
The findings: 1)No evidence of perforation. No enteric contents within abdomen.
2)Massively dilated stomach with about 3000cc of gastric contents and air within the stomach.
3)Redundant colon without mass
4) Several small bowel adhesions without evidence of complete obstruction. Some loops are large
5)Atrophic left lobe of liver.
In other words, pretty much a negative exploration. There is a phenomenon known as Chilaiditi's Sign. Although this sign is primarily associated with colonic interposition, cases involving small bowel are mentioned as well. Fortunately he is doing well and will be discharged soon.
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