Pneumoperitoneum

Total Page：16

File Type：pdf, Size：1020Kb

Postgrad Med J: first published as 10.1136/pgmj.62.723.31 on 1 January 1986. Downloaded from Postgraduate Medical Journal (1986) 62, 31-32 Diagnostic Images Pneumoperitoneum Presented by L. Kreel Newham General Hospital, London E13, UK. The patient A male age 66 years was admitted with a 6 month history of abdominal distension, and attacks of central abdominal pain and vomiting. The provisional diagnoses were cholelithiasis or chronic pancreatitis. Chest and abdominal radiographs were ordered (Figures 1 and 2), and oesophagogastroduodenoscopy performed which was normal. Barium enema showed diverticula of the sigmoid colon; small bowel enema was then carried out. by copyright. http://pmj.bmj.com/ on September 27, 2021 by guest. Protected Figure 1 Chest radiograph showing pneumoperitoneum Figure 2 Supine abdominal film. The wall ofthe colon is with more gas under the left hemidiaphragm than under clearly visible because of the gas both within the lumen the right. and in the peritoneal cavity. In addition there are small 'balloons' (arrows) containing gas with clearly demar- cated walls due to large small bowel diverticula. Colonic diverticula ofthe sigmoid are also shown, from a previous barium enema. D The Fellowship of Postgraduate Medicine, 1986 32 DIAGNOSTIC=~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~..:e..IMAGES Postgrad Med J: first published as 10.1136/pgmj.62.723.31 on 1 January 1986. Downloaded from .1. ^ ,g,~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ e... Figure 3z 1~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~.........'Small bowel enema (enteroclysis) demonstrat- Figure 4 Multiple diverticula of the small bowel shownby copyright. ing multiple duodenal diverticula. on small bowel enema. Diverticula of the sigmoid colon (arrows) from a previous barium enema are also visible. Comment Diverticula are found throughout the whole alimentary tract from the upper oesophagus to the distal colon with a marked variation in size and aetiology occurring most commonly in the siginoid colon and duodenum. Most diverticula are asymptomatic butcomplications include food retention particularly in Zenker's diverticulum in the hypopharynx. Haemorrhage is associated with a Meckel's diverticulum ofthe terminal ileum and pericolic abscesshttp://pmj.bmj.com/ with sigmoid diverticula where there is usually marked circular muscle spasm. Colonic diverticula can also perforate. Duodenal diverticula are common and almost always asymptomatic while those in the small bowel may produce malabsorption. Two papers reporting rare complications of the diverticula in the latter two sites have appeared in recent issues of this Journal (Stebbings & Thomson, 1985; Clarke & Kettlewell, 1985). Although this patient had sigmoid diverticula, perforation of a diverticulum in this region is usually into retroperitoneal tissues and not free into the peritoneal cavity. While not proven, perforation of a small bowel diverticulum was considered to be the most likely source ofthe pneumoperitoneum. The patient's symptoms were on September 27, 2021 by guest. Protected attributed to the pneumoperitoneum and disappeared as the pneumoperitoneum resolved. References STEBBINGS, W.S.L. & THOMSON, J.P.S. (1985). Perforated CLARKE, P.J. & KETTLEWELL, M.G.W. (1985). Small bowel duodenal diverticulum: a report oftwo cases. Postgraduate obstruction due to an enterolith originating in a jejunal Medical Journal, 61, 839. diverticulum. Postgraduate Medical Journal, 61, 1019..

Copy Link

Recommended publications

Diverticular Disease 1
WGO Practice Guidelines Diverticular disease 1 World Gastroenterology Organisation Practice Guidelines: Diverticular Disease Core review team: Dr. T. Murphy Prof. R.H. Hunt Prof. M. Fried Dr. J.H. Krabshuis Contents 1 Definitions 2 Epidemiology 3 Etiology 4 Pathophysiology 5 Medical and surgical management 6 Other forms of diverticular disease 7 Global aspects 8 References 9 Useful web sites 10 WGO Practice Guidelines Committee members who contributed to this guideline 11 Queries and feedback 1 Definitions Diverticulum: • A sac-like protrusion of mucosa through the muscular colonic wall [1]. • Protrusion occurs in weak areas of the bowel wall through which blood vessels can penetrate. • Typically 5–10 mm in size. • Diverticula are really pseudodiverticular (false diverticula), as they contain only mucosa and submucosa covered by serosa. Diverticular disease consists of: • Diverticulosis: the presence of diverticula within the colon • Diverticulitis: inflammation of a diverticulum • Diverticular bleeding Types of diverticular disease: © World Gastroenterology Organisation, 2007 WGO Practice Guidelines Diverticular disease 2 • Simple (75%), with no complications • Complicated (25%), with abscesses, fistula, obstruction, peritonitis, and sepsis 2 Epidemiology Prevalence by age [1]: • Age 40: 5% • Age 60: 30% • Age 80: 65% Prevalence by sex: • Age < 50: more common in males • Age 50–70: slight preponderance in women • Age > 70: more common in women Diverticular disease in the young (< 40) Diverticular disease is far more frequent in older people, with only 2–5% of cases occurring in those under 40 years of age. In this younger age group, diverticular disease occurs more frequently in males, with obesity being a major risk factor (present in 84–96% of cases) [2,3].
[Show full text]
Jejunoileal Diverticulitis: Big Trouble in Small Bowel
Jejunoileal Diverticulitis: Big Trouble in Small Bowel MICHAEL CARUSO DO, HAO LO MD EMERGENCY RADIOLOGY, UMASS MEMORIAL MEDICAL CENTER, WORCESTER, MA LEARNING OBJECTIVES: After excluding Meckel’s diverticulum, less than 30% of reported diverticula occurred in the CASE 1 1. Be aware of the relatively rare diagnoses of jejunoileal jejunum and ileum. HISTORY: 52 year old female with left upper quadrant pain. diverticulosis (non-Meckelian) and diverticulitis. Duodenal diverticula are approximately five times more common than jejunoileal diverticula. FINDINGS: 2.2 cm diverticulum extending from the distal ileum with adjacent induration of the mesenteric fat, consistent with an ileal diverticulitis. 2. Learn the epidemiology, pathophysiology, imaging findings and differential diagnosis of jejunoileal diverticulitis. Diverticulaare sac-like protrusions of the bowel wall, which may be composed of mucosa and submucosa only (pseudodiverticula) or of all CT Findings (2) layers of the bowel wall (true . Usually presents as a focal area of bowel wall thickening most prominent on the mesenteric side of AXIAL AXIAL CORONAL diverticula) the bowel with adjacent inflammation and/or abscess formation . Diverticulitis is the result of When abscess is present, CT findings may include relatively smooth margins, areas of low CASE 2 obstruction of the neck of the attenuation within the mass, rim enhancement after IV contrast administration, gas within the HISTORY: 62 year old female with epigastric and left upper quadrant pain. diverticulum, with subsequent mass, displacement of the surrounding structures, and edema of thickening of the surrounding fat inflammation, perforation and or fascial planes FINDINGS: 4.7 cm diameter out pouching seen arising from the proximal small bowel and associated with adjacent inflammatory stranding.
[Show full text]
Massive Pneumoperitoneum Presenting As an Incidental Finding
Open Access Case Report DOI: 10.7759/cureus.2787 Massive Pneumoperitoneum Presenting as an Incidental Finding Harry Wang 1 , Vivek Batra 2 1. Internal Medicine, Thomas Jefferson University Hospitals, Philadelphia, USA 2. Medical Oncology, Thomas Jefferson University Hospital, Philadelphia, USA Corresponding author: Harry Wang, [email protected] Abstract Pneumoperitoneum is often associated with surgical complications or intra-abdominal sepsis. While commonly deemed a surgical emergency, pneumoperitoneum in a minority of cases does not involve a viscus perforation or require urgent surgical management; these cases of “spontaneous pneumoperitoneum” can stem from a variety of etiologies. We report a case of a 72-year-old African American male with a history of metastatic pancreatic adenocarcinoma who presented with new-onset abdominal distention and an incidentally discovered massive pneumoperitoneum with no clear source of perforation on surveillance imaging. His exam was non-peritonitic, so no surgical intervention was recommended. He was treated with bowel rest, intravenous antibiotics, and hydration. He had a relatively benign clinical course with preserved gastrointestinal function and had complete resolution of his pneumoperitoneum on imaging two months after discharge. This case highlights the importance of considering non-surgical causes of pneumoperitoneum, as well as conservative management, when approaching patients with otherwise benign abdominal exams. Categories: Internal Medicine, Gastroenterology, Oncology Keywords: spontaneous pneumoperitoneum, pneumoperitoneum, pancreatic cancer, incidental finding Introduction Pneumoperitoneum is defined as the presence of free air within the peritoneal cavity. In the vast majority of cases (approximately 90%), this is a result of an intra-abdominal viscus perforation, often requiring intravenous antibiotics and acute surgical intervention [1].
[Show full text]
Spontaneous Pneumoperitoneum with Duodenal
Ueda et al. Surgical Case Reports (2020) 6:3 https://doi.org/10.1186/s40792-019-0769-4 CASE REPORT Open Access Spontaneous pneumoperitoneum with duodenal diverticulosis in an elderly patient: a case report Takeshi Ueda* , Tetsuya Tanaka, Takashi Yokoyama, Tomomi Sadamitsu, Suzuka Harada and Atsushi Yoshimura Abstract Background: Pneumoperitoneum commonly occurs as a result of a viscus perforation and usually presents with peritoneal signs requiring emergent laparotomy. Spontaneous pneumoperitoneum is a rare condition characterized by intraperitoneal gas with no clear etiology. Case presentation: We herein report a case in which conservative treatment was achieved for an 83-year-old male patient with spontaneous pneumoperitoneum that probably occurred due to duodenal diverticulosis. He had stable vital signs and slight epigastric discomfort without any other signs of peritonitis. A chest radiograph and computed tomography showed that a large amount of free gas extended into the upper abdominal cavity. Esophagogastroduodenoscopy showed duodenal diverticulosis but no perforation of the upper gastrointestinal tract. He was diagnosed with spontaneous pneumoperitoneum, and conservative treatment was selected. His medical course was uneventful, and pneumoperitoneum disappeared after 6 months. Conclusion: In the management of spontaneous pneumoperitoneum, recognition of this rare condition and an accurate diagnosis based on symptoms and clinical imaging might contribute to reducing the performance of unnecessary laparotomy. However, in uncertain cases with peritoneal signs, spontaneous pneumoperitoneum is difficult to differentiate from free air resulting from gastrointestinal perforation and emergency exploratory laparotomy should be considered for these patients. Keywords: Spontaneous pneumoperitoneum, Duodenal diverticulosis, Conservative management Background therapy. We also discuss the possible etiology and clin- Pneumoperitoneum is caused by perforation of intraperito- ical issues in the management of this rare condition.
[Show full text]
Paraesophageal Hernia
Paraesophageal Hernia a, b Dmitry Oleynikov, MD *, Jennifer M. Jolley, MD KEYWORDS Hiatal Paraesophageal Nissen fundoplication Hernia Laparoscopic KEY POINTS A paraesophageal hernia is a common diagnosis with surgery as the mainstay of treatment. Accurate arrangement of ports for triangulation of the working space is important. The key steps in paraesophageal hernia repair are reduction of the hernia sac, complete dissection of both crura and the gastroesophageal junction, reapproximation of the hiatus, and esophageal lengthening to achieve at least 3 cm of intra-abdominal esophagus. On-lay mesh with tension-free reapproximation of the hiatus. Anti-reflux procedure is appropriate to restore lower esophageal sphincter (LES) competency. INTRODUCTION Hiatal hernias were first described by Henry Ingersoll Bowditch in Boston in 1853 and then further classified into 3 types by the Swedish radiologist, Ake Akerlund, in 1926.1,2 In general, a hiatal hernia is characterized by enlargement of the space be- tween the diaphragmatic crura, allowing the stomach and other abdominal viscera to protrude into the mediastinum. The cause of hiatal defects is related to increased intra-abdominal pressure causing a transdiaphragmatic pressure gradient between the thoracic and abdominal cavities at the gastroesophageal junction (GEJ).3 This pressure gradient results in weakening of the phrenoesophageal membrane and widening of the diaphragmatic hiatus aperture. Conditions that are associated with increased intra-abdominal pressure are those linked
[Show full text]
Pneumoperitoneum: an Unusual Presenting Finding of Perforated Appendicitis in Children Levent Duman
20 Case report Pneumoperitoneum: an unusual presenting finding of perforated appendicitis in children Levent Duman Pneumoperitoneum is rarely encountered as a surgical abdominal emergencies in children. However, very radiographic finding in association with perforated young children often pose a diagnostic dilemma for the appendicitis in children, and may lead to diagnostic clinician. Pneumoperitoneum is a confusing finding in errors. In this paper, we present pneumoperitoneum as perforated appendicitis, and may lead to diagnostic errors. a presenting finding of perforated appendicitis in a However, it may be considered as a favorable sign because 2-year-old boy. it will result in the patient’s immediate surgical exploration and cure. Ann Pediatr Surg 10:20–21 c 2014 Annals of The term pneumoperitoneum frequently indicates Pediatric Surgery. perforation of an intra-abdominal hollow viscus. However, it is rarely encountered as a radiographic finding in Annals of Pediatric Surgery 2014, 10:20–21 association with perforated appendicitis. The cases Keywords: appendicitis, children, pneumoperitoneum reported in the literature are mostly adult patients, but the Department of Pediatric Surgery, Su¨leyman Demirel University Medical School, relevant data in children are limited. Here, we present a Isparta, Turkey case of a 2-year-old boy with perforated appendicitis Correspondence to Levent Duman, MD, Department of Pediatric Surgery, who presented with pneumoperitoneum. The patient was Su¨leyman Demirel University Medical School, 32260 Isparta, Turkey taken into the operation theater with an initial diagnosis Tel: + 90 246 2119249; fax: + 90 246 2371758; e-mail: [email protected] of gastrointestinal perforation. Surgical exploration Received 21 July 2013 accepted 26 October 2013 indicated a perforated appendix and an appendectomy was performed.
[Show full text]
Brief Reports Enteroliths in a Meckel's Diverticulum Mimicking Gallstone
brief reports Enteroliths in a Meckel’s Diverticulum Mimicking Gallstone Ileus Peter G. Justus, MD, James J. Bergman, MD, and Thomas R. Reagan, MD Redmond, W ashington allstone ileus is a form of mechanical obstruction of pain. The recurring symptoms had a duration of several G the small intestine caused by a large gallstone that hours, each time culminating in severe distress lasting 10 has passed from the gallbladder to the intestine through to 15 minutes. Progressive fatigue and episodic anorexia acholecystoenteral fistula.1 This diagnosis is suspected in pursued. He denied fatty food intolerance, jaundice, vom patients with gallstones and symptoms or signs of inter iting, or a past history of gastrointestinal disease. The mittent small-bowel obstruction. family history and other personal history were unremark Meckel’s diverticulum, the most common malformation able. of the gastrointestinal tract, is found in about 2 percent On examination the patient was well nourished and in of individuals.2 Its rare clinical manifestations include in no acute distress. He was normotensive, afebrile, and testinal obstruction, ulceration, hemorrhage, intussus nonicteric. The abdomen was mildly distended, and there ception, and neoplasm. Such phenomena usually are not was mild tenderness to deep palpation of the right upper diagnosed preoperatively.3 Some 50 cases of enteroliths quadrant. No rebound or guarding was elicited, nor were occurring in a Meckel’s diverticulum have been reported.4 there masses noted. Rectal examination was negative, al This unusual finding occurs most often in men and can though some brown, guaiac-positive stool was recovered. present with lower abdominal pain, vomiting,5 rectal The remainder of the physical examination was within bleeding,6 anemia,7 or bowel obstruction.8 Radiographs normal limits.
[Show full text]
Jejunal Diverticula Causing a Life-Threatening Lower
Available online at www.ijmrhs.com cal R edi ese M ar of c l h a & n r H u e o a J l l t h International Journal of Medical Research & a S n ISSN No: 2319-5886 o c i t i Health Sciences, 2019, 8(4): 196-200 e a n n c r e e t s n I • • IJ M R H S Jejunal Diverticula Causing a Life-Threatening Lower Gastrointestinal Bleeding: A Case Report Abdelmoniem MM Makkawi* and Mohammed Eltoum Hamid Azoz Department of Surgery, University of Elimam Elmahadi, Kosti, Sudan *Corresponding e-mail: [email protected] ABSTRACT A jejunal diverticulum is a rare and usually asymptomatic disease. More commonly it is usually seen as incidental findings on radiological studies or during surgery. Complications such as bleeding, perforation, abscess formation, obstruction, malabsorption, blind loop syndrome, volvulus, and intussusception may warrant surgical intervention. Herein, we report a case of a 62-year old woman presenting with massive lower gastrointestinal bleeding, she was pale, clammy and hemodynamically unstable, she was initially resuscitated with IV fluids and whole blood, urgent upper endoscopy was normal, colonoscopy revealed sigmoid colon ulcerative lesion with histopathological evidence of adenocarcinoma, there was bleeding coming from upwards. After staging of the tumor, the decision was then made to proceed to exploratory laparotomy with a pre-operative plan of segmental colectomy. Intra-operatively segmental sigmoid colectomy was performed with end to end anastomosis, during formal laparotomy we found 2 giant diverticula in the proximal jejunum, small bowel resection and end to end anastomosis was done with the good postoperative outcome.
[Show full text]
Femoral Hernia Causing Pneumoperitoneum
Postgraduate Medical Journal (1986) 62, 675-676 Postgrad Med J: first published as 10.1136/pgmj.62.729.675 on 1 July 1986. Downloaded from Femoral hernia causing pneumoperitoneum H.A. King and P.S. Boulter St Luke's Hospital, Warren Road, Guildford, Surrey GUI 3NT, UK. Summary: Richter's hernia, in which only a portion ofthe circumference ofthe intestine lies within the sac, is a common complication offemoral hernia. This case report is ofa 39 year old female who presented with apneumoperitoneum and was found at laparotomy to have a right femoral Richter's hernia containing a knuckle of perforated small bowel. This is a previously unreported presentation of femoral hernia. Introduction Richter's hernia, in which only a portion of the circumference of the intestine lies within the sac, is a common complication of femoral hernia. The bowel can strangulate and perforate but pneumoperitoneum has never been reported as a complication. Case report A 39 year old female presented with a 10-day history of copyright. generalized abdominal discomfort associated with bile stained vomiting and gross abdominal distension. Her bowels had opened daily. There was no history of previous episodes, dyspepsia or alteration in bowel habit. She had had no previous operations and was otherwise well. On examination, she was dehydrated and febrile (37.5'C), pulse rate 90/min. The abdomen was grossly http://pmj.bmj.com/ distended and tympanitic, diffusely tender but without guarding or rebound tenderness. The hernial orifices were intact. Bowel sounds were quiet and not obstruc- tive. Rectal examination demonstrated only tender- ness anteriorly.
[Show full text]
Zenker's Diverticulum and Squamous Esophageal Cancer
Journal of Mind and Medical Sciences Volume 4 | Issue 2 Article 15 2017 Zenker’s diverticulum and squamous esophageal cancer: a case report Ion Dina Carol Davila University, St. Ioan Clinical Hospital, Department of Gastroenterology, Bucharest, Romania Octav Ginghina Carol Davila University, St. Ioan Clinical Hospital, Department of Surgery, Bucharest, Romania Corina D. Toderescu Vasile Goldis Western University of Arad, Faculty of General Medicine, Arad, Romania Cristian Bălălău Carol Davila University, St. Pantelimon Hospital, Department of Surgery, Bucharest, Romania, [email protected] Bianca Galateanu University of Bucharest, Department of Biochemistry and Molecular Biology, Bucharest, Romania See next page for additional authors Follow this and additional works at: http://scholar.valpo.edu/jmms Part of the Medical Sciences Commons, and the Surgery Commons Recommended Citation Dina, Ion; Ginghina, Octav; Toderescu, Corina D.; Bălălău, Cristian; Galateanu, Bianca; Negrei, Carolina; and Iacobescu, Claudia (2017) "Zenker’s diverticulum and squamous esophageal cancer: a case report," Journal of Mind and Medical Sciences: Vol. 4 : Iss. 2 , Article 15. DOI: 10.22543/7674.42.P193197 Available at: http://scholar.valpo.edu/jmms/vol4/iss2/15 This Case Presentation is brought to you for free and open access by ValpoScholar. It has been accepted for inclusion in Journal of Mind and Medical Sciences by an authorized administrator of ValpoScholar. For more information, please contact a ValpoScholar staff member at [email protected]. Zenker’s diverticulum and squamous esophageal cancer: a case report Authors Ion Dina, Octav Ginghina, Corina D. Toderescu, Cristian Bălălău, Bianca Galateanu, Carolina Negrei, and Claudia Iacobescu This case presentation is available in Journal of Mind and Medical Sciences: http://scholar.valpo.edu/jmms/vol4/iss2/15 J Mind Med Sci.
[Show full text]
Management of Complications After Paraesophageal Hernia Repair
10 Review Article Page 1 of 10 Management of complications after paraesophageal hernia repair Abraham J. Botha, Francesco Di Maggio Department of Upper GI Surgery, St Thomas Hospital, Guys and St Thomas NHS Foundation Trust, London, United Kingdom Contributions: (I) Conception and design: AJ Botha; (II) Administrative support: None; (III) Provision of study materials or patients: None; (IV) Collection and assembly of data: All authors; (V) Data analysis and interpretation: None; (VI) Manuscript writing: All authors; (VII) Final approval of manuscript: All authors. Correspondence to: Abraham J. Botha. Consultant Upper Gastro-intestinal surgeon, Department of Surgery, St Thomas Hospital. Westminster Bridge Road, SE1 7EH London, United Kingdom. Email: [email protected]. Abstract: Laparoscopic paraesophageal hernia (PEH) repair can be performed safely in expert hands. However, it is a complex operation carrying significant risk of peri-operative morbidity and mortality. Careful intra-operative correctional techniques and prompt return to theatre for early post-operative complications result in a satisfactory outcome. Capnothorax and pneumothorax should be dealt with immediately by lowering insufflation pressure, aspiration and drain placement. Hemodynamic instability from cardiovascular injury or bleeding mandates an early return to theatre. Intra-operative perforation of the esophagus or stomach is best avoided, but it can be successfully repaired. Early acute dysphagia warrants a return to theatre for correction while delayed dysphagia can in some patients be treated by dilatation. Asymptomatic hiatus hernia recurrence does not require surgery, but symptomatic and complicated hernias can be re-repaired. Some life-threatening complications such as acute gastric dilatation, aortic fistula, gastric necrosis and perforation can occur months, and even years, after the procedure.
[Show full text]
Clinics in Diagnostic Imaging (162)
Singapore Med J 2015; 56(9): 523-527 Medical Education doi: 10.11622/smedj.2015138 CMEARTICLE Clinics in diagnostic imaging (162) Dinesh R Singh1, MMed, FRCR, Geoiphy G Pulickal1, MMed, FRCR, Zhiwen J Lo2, MBBS, BMed, Wilfred CG Peh1, FRCP, FRCR Fig. 1 Contrast-enhanced axial CT image. 2a 2b Fig. 2 Tc-99m pertechnetate (a) anterior planar scintigraphy and (b) sagittal single-photon emission computed tomography (SPECT)/CT fusion images. CASE PRESENTATION rectal examination, no masses were felt. Computed tomography A 28-year-old Chinese man presented to the accident and (CT) was performed to identify the possible cause of bleeding emergency department with active bleeding per rectum. The (Fig. 1). Nuclear medicine scintigraphy using technetium (Tc)- patient had experienced similar bouts of bleeding in the preceding 99m pertechnetate was performed the following day to obtain two years and was treated symptomatically. He was stable on anterior planar (Fig. 2a) and single-photon emission computed clinical examination and had normal blood pressure, pulse rate tomography (SPECT)/CT fusion (Fig. 2b) images. What do the CT and respiratory rate. Although there was altered blood on digital and scintigraphy images show? What is the diagnosis? 1Department of Diagnostic Radiology, 2Department of General Surgery, Khoo Teck Puat Hospital, Singapore Correspondence: Dr Dinesh R Singh, Registrar, Department of Diagnostic Radiology, Khoo Teck Puat Hospital, Alexandra Health, 90 Yishun Central, Singapore 768828. [email protected] 523 Medical Education IMAGE INTERPRETATION Contrast-enhanced axial CT image (Fig. 1) shows posterior outpouching from a segment of the distal ileum (arrows) associated with mild wall thickening and increased mucosal enhancement.
[Show full text]