Pneumobilia: Hepatic Gas Applied

Brief HPI

A 45 year-old female with a history of pre-diabetes and gastroesophageal reflux disease presents with 3 days of epigastric abdominal pain. She describes constant, burning abdominal pain which worsened on the day of presentation associated with two episodes of non-bloody and non-bilious emesis. The patient was tender to palpation in the epigastrium and right upper quadrant.

Right upper quadrant ultrasound

Ultrasound

Laboratory studies were largely normal. A complete blood count demonstrated minimal leukocytosis (11.6 with normal differential), and liver function tests were normal.

A right-upper quadrant ultrasound was obtained which demonstrated “strongly shadowing structures in the gallbladder fossa which might represent a wall-echo-shadow, calcified gallbladder wall, or air within the gallbladder”.

The patient underwent contrast-enhanced computed tomography of the abdomen and pelvis which is shown below.

Imaging

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CT Abdomen/Pelvis with Contrast

Pneumobilia, intra- and extra-hepatic biliary duct dilation, pericholecystic fat stranding, and an air-fluid level within a contracted gallbladder. Mildly dilated loops of ileal bowel with a possible transition point in the right lower quadrant. Findings suggestive of possible gallstone ileus.

The patient was taken to the operating room for exploratory laparotomy, possible cholecystectomy and possible small bowel resection for presumed gallstone ileus. Intra-operative findings were notable for a cholecystogastric fistula which was repaired.

Differentiation between Portal Venous Gas and Pneumobilia

The patient’s CT demonstrated mostly central hepatic gas. This finding combined with the presence of an air-fluid level in the gallbladder was most consistent with pneumobilia. This case demonstrates an application of the previously-developed algorithm for the evaluation of hepatic gas in a relatively unique pathologic process.
Hepatic Gas: Pneumobilia  vs. Portal Venous Gas

Pediatric Foreign Body Ingestion

Brief H&P

XR Chest: Circular radioopaque foreign body likely in the antrum of the stomach.

A healthy 5 year-old boy is brought to the pediatric emergency department after he informed his parents that he accidentally swallowed a coin just prior to presentation. He has no complaints and on evaluation appears to be breathing comfortably and is tolerating secretions normally. A plain radiograph was obtained and is shown below.

The patient remained well-appearing and was discharged with primary care follow-up.


Indications for Emergent Endoscopy

  • Esophageal button battery
  • Severe symptoms
  • Sharp foreign body in esophagus
  • Multiple magnets in esophagus or stomach

Radiographic Findings


Esophageal foreign bodies typically orient coronally. For example, a coin will appear as a circle on an anteroposterior projection.

Tracheal foreign bodies typically orient sagitally. For example a coin will appear as a line on an anteroposterior projection.

Algorithm for the Evaluation and Management of Pediatric Foreign Body Aspiration

Algorithm for the Management of Pediatric Foreign Body Ingestion

References

  1. Sahn, B, et al. Foreign Body Ingestion Clinical Pathway. 1 Aug. 2016, www.chop.edu/clinical-pathway/foreign-body-ingestion-clinical-pathway. Accessed 26 Aug. 2017.
  2. Wyllie R. Foreign bodies in the gastrointestinal tract. Current Opinion in Pediatrics. 2006;18 N2 -(5).
  3. Uyemura MC. Foreign body ingestion in children. Am Fam Physician. 2005;72(2):287-291.
  4. Chung S, Forte V, Campisi P. A Review of Pediatric Foreign Body Ingestion and Management. Vol 11. 2010:225-230.
  5. Louie MC, Bradin S. Foreign Body Ingestion and Aspiration. Pediatrics in Review. 2009;30(8):295-301. doi:10.1542/pir.30-8-295.
  6. Green SS. Ingested and Aspirated Foreign Bodies. Pediatrics in Review. 2015;36(10):430-437. doi:10.1542/pir.36-10-430.

Acute Urinary Retention

Brief H&P:

A 62 year-old male with no significant medical history, presented to the emergency department with several days of vomiting. Examination showed suprapubic fullness with tenderness to palpation and a bedside ultrasound was performed:

RUQ
RUQ

RUQ

Right upper quadrant ultrasound with moderate hydronephrosis.

LUQ
LUQ

LUQ

Left upper quadrant ultrasound with moderate hydronephrosis.

Bladder
Bladder

Bladder

Relatively non-distended bladder.

Bladder Volume
Bladder Volume

Bladder Volume

Post-void bladder volume.

Ultrasound revealed moderate bilateral hydronephrosis with a relatively non-distended bladder. Labs were notable for new renal failure and the patient was admitted for continued evaluation. He was ultimately diagnosed with idiopathic retroperitoneal fibrosis with bilateral distal ureteral obstruction requiring stenting.

Anatomy of Acute Urinary Retention:

Differential Diagnosis of Acute Urinary Retention:1,2,3

Algorithm for the Evaluation of Acute Urinary Retention

 

Hypotension

Brief H&P:

A 50 year-old male with a history of colonic mucinous adenocarcinoma on chemotherapy presented with a chief complaint of “vomiting”. He was unwilling to provide further history, repeating that he had vomited blood prior to presentation. His initial vital signs were notable for tachycardia. Physical examination showed some dried vomitus, brown in color, at the nares and lips; left upper quadrant abdominal tenderness to palpation; and guaiac-positive stool. Point-of-care hemoglobin was 3g/dL below the most recent measure two months prior. As his evaluation progressed, he developed hypotension and was transfused two units of uncrossmatched blood with adequate blood pressure response – he was started empirically on broad-spectrum antibiotics for an intra-abdominal source. Notable laboratory findings included a normal hemoglobin/hematocrit, acute kidney injury, and elevated anion gap metabolic acidosis presumably attributable to serum lactate of 10.7mmol/L. Computed tomography of the abdomen and pelvis demonstrated pneumoperitoneum with complex ascites concerning for bowel perforation. The patient deteriorated, was intubated, started on vasopressors and admitted to the surgical intensive care unit. The initial operative report noted extensive adhesions and perforated small bowel with feculent peritonitis. He has since undergone multiple further abdominal surgeries and remains critically ill.

Imaging

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CT Abdomen/Pelvis

Free air is seen diffusely in the non-dependent portions of the abdomen: in the anterior abdomen and pelvis, inferior to the diaphragm, and in the perisplenic region. There is complex free fluid in the abdomen.

Algorithm for the Evaluation of Hypotension1

This process for the evaluation of hypotension in the emergency department was developed by Dr. Ravi Morchi. In the case above, a systematic approach to the evaluation of hypotension using ultrasonography and appropriately detailed physical examination may have expedited the patient’s care. The expertly-designed algorithm traverses the cardiovascular system, halting at evaluable checkpoints that may contribute to hypotension.

  1. The process begins with the cardiac conduction system to identify malignant dysrhythmias (bradycardia, or non-sinus tachycardia >170bpm), which, in unstable patients are managed with electricity.
  2. The next step assesses intravascular volume with physical examination or bedside ultrasonography of the inferior vena cava. Decreased right atrial pressure (whether due to hypovolemia, hemorrhage, or a distributive process) is evidenced by a small and collapsible IVC. If hemorrhage is suspected, further ultrasonography with FAST and evaluation of the abdominal aorta may identify intra- or retroperitoneal bleeding.
  3. If a normal or elevated right atrial pressure is identified, evaluate for dissociation between the RAP and left ventricular end-diastolic volume. This is typically caused by a pre- or intra-pulmonary obstructive process such as tension pneumothorax, cardiac tamponade, massive pulmonary embolism, pulmonary hypertension, or elevated intra-thoracic pressures secondary to air-trapping. Thoracic ultrasonography can identify pneumothorax, pericardial effusion, or signs of elevated right ventricular systolic pressures (RV:LV, septal flattening).
  4. Assuming adequate intra-vascular volume is arriving at the left ventricle, rapid echocardiography can be used to provide a gross estimate of cardiac contractility and point to a cardiogenic process. If there is no obvious pump failure, auscultation may reveal murmurs that would suggest systolic output is refluxing to lower-resistance routes (ex. mitral insufficiency, aortic insufficiency, or ventricular septal defect).
  5. Finally, if the heart rate is suitable, volume deficits are not grossly at fault, no obstructive process is suspected, and cardiac contractility is adequate and directed appropriately through the vascular tree, the cause may be distributive. Physical examination may reveal dilated capillary beds and low systemic vascular resistance.

Algorithm for the Evaluation of Hypotension

References

  1. Morchi R. Diagnosis Deconstructed: Solving Hypotension in 30 Seconds. Emergency Medicine News. 2015.

Portal Venous Gas

Brief HPI

Young male with no significant medical history presenting with progressively worsening right lower quadrant abdominal pain with marked tenderness to palpation and involuntary guarding.

Imaging

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CT Abdomen/Pelvis with Contrast

Inflammatory changes in the right lower quadrant concerning for ruptured appendicitis with approximately 9 cm abscess.
Gas in the liver likely representing portal venous gas which can be seen in the setting of appendicitis vs less likely secondary to bowel ischemia.

Differentiation between Portal Venous Gas and Pneumobilia

Portal venous gas vs. Pneumobilia

References

  1. Rabou Ahmed A and Frank Gaillard. “Pneumobilia.” Radiopaedia. http://radiopaedia.org/articles/pneumobilia.
  2. Morgan Matt A and Donna D’Souza. “Portal venous gas.” Radiopaedia. http://radiopaedia.org/articles/portal-venous-gas
  3. Sebastià C, Quiroga S, Espin E, Boyé R, Alvarez-Castells A, Armengol M. Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. Radiographics. 2000;20(5):1213–24–discussion1224–6. doi:10.1148/radiographics.20.5.g00se011213.
  4. Sherman SC, Tran H. Pneumobilia: benign or life-threatening. J Emerg Med. 2006;30(2):147-153. doi:10.1016/j.jemermed.2005.05.016.

Abdominal Pain

Pathophysiology of Abdominal Pain

  1. Visceral: distension of hollow organs or capsular stretch of solid organs.
  2. Somatic: parietal peritoneal irritation
  3. Referred

    • Extra-abdominopelvic

      • Epigastric: inferior MI
      • Pelvic: hip
      • Abdominal: lower lobe pneumonia/infarction
    • Abdominopelvic

      • Shoulder: diaphragmatic irritation (ex. perforated duodenal ulcer, splenic pathology)
      • Mid-back: aortopathy, pancreatitis
      • Flank: renal pathology
      • Low back: uterus, rectum

Concerning Historical Features

  • Elderly: increased probability for severe disease with poor clinical diagnostic accuracy
  • Immunocompromised: HIV/AIDS, uncontrolled diabetes, chronic liver disease, chemotherapy, other immunosuppression
  • Pain preceding nausea/vomiting: increased likelihood of surgical process
  • Abrupt onset, duration <48h, constant timing
  • Prior abdominal surgical history: consider bowel obstruction
  • No prior episodes of similar pain
  • Recent antibiotic or steroid use: may mask signs of infection
  • Cardiac risk factors (HTN, vascular disease, atrial fibrillation: increased risk for mesenteric ischemia or aortic aneurysm
  • Heavy NSAID use or anticoagulation: increase concern for gastrointestinal bleeding

Imaging

  • Plain film reserved for those who would otherwise not undergo CT. XR abdomen for bowel obstruction or radiopaque foreign body.
  • CT abdomen/pelvis with IV contrast, particularly if elderly or immunocompromised.
  • Ultrasound preferred for hepatobiliary pathology
  • Bedside ultrasound for identification of IUP, free intraperitoneal fluid, cholecystitis, CBD dilation, ascites, hydronephrosis, aortopathy, volume status.

Causes of Abdominal Pain

Causes of Abdominal Pain

References

  1. Budhram, G., & Bengiamin, R. (2013). Abdominal Pain. In Rosen’s Emergency Medicine – Concepts and Clinical Practice (8th ed., Vol. 1, pp. 223-231). Elsevier Health Sciences.

Ectopic Pregnancy

HPI:

32F G8P7A2 at 5 weeks by LMP presenting with abdominal pain. The patient reports acute onset of sharp left lower abdominal pain 1.5 hours prior to presentation. The pain has been constant since onset, 10/10 in severity, radiating to lower back and exacerbated with movement. She denies vaginal bleeding or discharge, passage of clots or other products. She also denies trauma, lightheadedness/dizziness/syncope, shortness of breath, nausea/vomiting or changes in bowel or urinary habits.
Her pregnancy was detected 3 weeks ago with a home pregnancy test and was confirmed at her PCP one week later. She has not had an ultrasound during this pregnancy but has a history of uterine fibroids. She has no history of sexually transmitted infections, prior ectopic pregnancy, or use of assisted fertilization.

PMH:

  • HTN
  • Uterine fibroids

PSH:

None

FH:

Non-contributory

SHx:

  • Denies tobacco, alcohol or drug use.
  • Sexually active with husband only, no history of STI.

Meds:

None

Allergies:

NKDA

Physical Exam:

VS: T 37.4 HR 108 RR 36 BP 148/104 O2 99% RA
Gen: Alert and oriented female, appears uncomfortable due to pain.
HEENT: PERRL, EOMI, MMM.
CV: Tachycardia, regular rhythm, no murmurs.
Lungs: CTAB, no crackles.
Abd: Normoactive bowel sounds, tenderness to palpation in LLQ and suprapubic area, with guarding but no rebound tenderness. No CVAT.
GU: No external lesions. Closed cervical os, no blood or discharge, +CMT.
Ext: Warm, well-perfused with strong peripheral pulses.

Labs/Studies:

  • POC Hemoglobin: 11.8
  • POC ICON: positive

Imaging:

Bedside Ultrasound

  1. Transabdominal: Free fluid in hepatorenal and splenorenal recesses
  2. Transvaginal: Free fluid and debris in posterior cul-de-sac, likely pseudogestational sac in endometrial cavity, no IUP identified. Formal ultrasound revealed fetus with cardiac activity in left adnexa.
Hepatorenal free fluid

Hepatorenal free fluid

Free fluid in the hepatorenal recess (Morison's Pouch)

Splenorenal Free Fluid

Splenorenal Free Fluid

Free fluid in the splenorenal recess.

Pelvic Free Fluid

Pelvic Free Fluid

Free fluid and debris in the posterior cul-de-sac.

Pseudogestational Sac

Pseudogestational Sac

No obvious yolk sac or fetal pole.

Assessment/Plan:

32 year-old ICON positive female with acute-onset pelvic pain. The patient remained hemodynamically stable and absence of definitive IUP on bedside ultrasound was confirmed with presence of fetal cardiac activity in left adnexa indicative of ectopic pregnancy. OB-Gyn was consulted and the patient was taken emergently to the OR.

Differential Diagnosis of First Trimester Abdominal Pain: 1

Differential Diagnosis of 1st Trimester Abdominal Pain

Initial Evaluation of First Trimester Abdominal Pain: 1

  • 2 large-bore IV’s, begin fluid resuscitation
  • POC testing: hemoglobin, urine pregnancy
  • CBC, type and cross (Rh), serum B-hCG
  • Emergent bedside ultrasound

Features Associated with Ectopic Pregnancy: 1

  • History
    • PID
    • Tubal ligation
    • Prior ectopic
    • IUD
    • Assisted fertilization
  • Physical
    • CMT
    • Peritoneal irritation
  • Ultrasound
    • Empty uterus
    • Adnexal mass
    • Free fluid
  • Ultrasonographic Findings in the Evaluation of Ectopic Pregnancy: 2

    • Discriminatory hCG (1500-3000 mIU/mL): absence of IUP suggests ectopic or abnormal gestation
    • Normal IUP
      • 4-5wks: gestational sac (0.2-0.5cm)
      • 5wks: two echogenic rings
      • 5.5wks: yolk sac
      • 6wk: embryonic pole
      • 6.5wk: fetal cardiac activity
    • Abnormal IUP
      • >2cm gestational sac without fetal pole
      • CRL >0.5cm without cardiac activity
    • Ectopic
      • Extrauterine gestational sac with or without cardiac activity
      • Extrauterine ring sign
      • Non-homogenous adnexal mass

    Contraindications to Medical Management: 2,3

    • Absolute
      • Breast-feeding
      • Immunodeficiency
      • PUD
      • Pulmonary, hepatic or renal dysfunction
    • Relative
      • Ectopic mass > 3.5cm
      • Fetal cardiac activity

    References:

    1. Dart, R. (2003). First Trimester Emergencies A Practical Approach To Abdominal Pain And Vaginal Bleeding In Early Pregnancy. EB Medicine, 5(11), 1–20.
    2. Barnhart, K. T. (2009). Clinical practice. Ectopic pregnancy. The New England journal of medicine, 361(4), 379–387. doi:10.1056/NEJMcp0810384
    3. Jurkovic, D., & Wilkinson, H. (2011). Diagnosis and management of ectopic pregnancy. BMJ (Clinical research ed.), 342(jun10 1), d3397–d3397. doi:10.1136/bmj.d3397

    Volvulus


    Swirling mesenteric vessels in mid-pelvis associated with narrowed segments of small bowel and fluid-filled proximal small bowel raises concern for volvulus and small bowel obstruction.

    Alcoholic Hepatitis

    HPI:

    43 year-old female with a history of alcohol abuse and alcoholic hepatitis, presenting after referral from breast clinic for abnormal labs (notable for total bilirubin 18.1). The patient was well until two weeks ago when she noted increasing fatigue associated with morning nausea/vomiting (non-bloody) as well as yellowing of skin and eyes. She also reports darkening of urine, but no dysuria, change in volume of urine, or visible blood. She also denies fevers/chills, increased abdominal girth, abdominal pain, changes in bowel habits or bloody/dark stools.

    She reports drinking 1 pint of vodka daily for the past 15 years, and perhaps more in the past 3 weeks. Her last drink was in the morning on the day of admission, she denies any history of seizures and reports withdrawal symptoms (tremor, nausea) relieved with more alcohol. She currently denies anxiety/agitation, tactile/visual/auditory hallucinations.

    The patient was in breast clinic for evaluation of a painful breast mass which developed after biopsy of a lesion which was ultimately found to be benign. The patient noted the mass was growing in size and becoming more painful over the past month.

    PMH:

    • EtOH abuse
    • Alcoholic hepatitis

    PSH:

    • None

    FH:

    • No family history of breast/gynecologic malignancy.
    • Mother with history of stroke. Father with diabetes.

    SHx:

    • Lives alone.
    • Denies current or previous tobacco/drug use. Drinks 1 pint of whiskey daily for the past 15 years.
    • Not currently sexually active, no history of STI.

    Meds:

    • None

    Allergies:

    NKDA

    Physical Exam:

    VS: T 98.9 HR 104 RR 19 BP 117/67 O2 99% RA
    Gen: Well-appearing obese female in no acute distress
    HEENT: PERRL, marked scleral icterus, sublingual icterus, MMM, no lesions
    CV: Tachycardia, regular rhythm, normal S1/S2, no M/R/G
    Lungs: CTAB, no crackles/wheezing
    Abd: +BS, soft, non-distended, liver edge palpated 6cm below costal margin, irregular texture slightly tender to palpation, spleen not palpated, no fluid wave or shifting dullness, no rebound/guarding.
    Ext: Warm, well-perfused, 2+ pulses (DP/PT), slight yellowing.
    Skin: Vascular spiders on anterior chest, left breast with 5x5cm ecchymosis and tender underlying mass, no erythema, warmth, skin dimpling, nipple discharge.
    Neuro: AAOx4, CN II-XII intact, no tremor noted, gait normal.

    Labs/Studies:

    1mo prior to admission:

    • AST/ALT/AP/TB: 444/77/234/2.5

    Day 1:

    • AST/ALT/AP/TB: 185/61/184/18.1
    • PT/PTT/INR: 14.7/37.0/1.2

    Day 4:

    • AST/ALT/AP/TB: 142/50/153/25.5
    • PT/PTT/INR: 20.1/38.9/1.7

    Imaging:

    Abdominal US

    1. Markedly echogenic and enlarged liver with a nodular surface of cirrhosis.
    2. Markedly blunted hepatic vein waveforms commonly seen due to decreased hepatic parenchymal compliance although other etiologies causes of obstruction to hepatic venous outflow.
    3. Splenomegaly.

    Assessment/Plan:

    44F hx EtOH abuse, alcoholic hepatitis, presenting with acute alcoholic hepatitis.
    # Alcoholic hepatitis: Rapid onset of jaundice, tender hepatomegaly, and elevation of transaminases (AST > ALTx2) in the setting of chronic alcohol use suggestive of alcoholic hepatitis. Initial Maddrey discriminant hepatic function (mDH) score 37 suggestive of severe disease with high short-term mortality. Initiated trental 400mg p.o. t.i.d.
    # EtOH withdrawal: Last drink <24h ago, monitor for signs of withdrawal, treat with Ativan per withdrawal protocol. # Cirrhosis: Newly diagnosed on abdominal ultrasound. Complicated by coagulopathy, and likely portal hypertension given splenomegaly/thrombocytopenia. Plan for outpatient screening EGD and continued GI follow-up. # Breast mass: Likely hematoma 2/2 biopsy associated given increased size associated with progression of coagulopathy/thrombocytopenia. Outpatient ultrasound and follow-up scheduled. # Anemia: Macrocytic, potentially related to vitamin deficiency vs. bone-marrow suppression associated with chronic alcohol use. Start thiamine/folate/multivitamin. # FEN/GI/PPx: Encourage p.o. intake (2g sodium restriction), continue ondansetron p.r.n. nausea/vomiting, obtain nutrition consult.

    Hospital Course

    Patient’s liver function continued to decline as evidenced by worsening coagulopathy and increased serum bilirubin. mDH had increased to 58 by day four of hospitalization and steroids were added.

    Pathophysiology of Alcoholic Hepatitis: 1

    Ethanol promotes translocation of bacterial components (lipopolysaccharide) across the intestinal wall, into the portal venous system and liver. These trigger a local and systemic inflammatory response which leads to hepatocellular injury and systemic effects such as fever, anorexia and weight loss.

    Evaluation of Alcoholic Hepatitis: 1,2

    Clinical features:

    • Rapid onset jaundice
    • Tender hepatomegaly
    • Fever
    • Ascites
    • Proximal muscle loss
    • Encephalopathy

    Labs:

    • AST > ALT (x2), generally < 300IU/mL
    • Leukocytosis
    • ↑Total serum bilirubin
    • ↑INR
    • ↑Creatinine associated with poor prognosis

    Other studies:

    • Screening for infection: PNA, UTI, SBP
    • Abdominal US to evaluate hepatic abscess, HCC, extrahepatic biliary obstruction

    Management of Alcoholic Hepatitis: 1,2

    Grading Severity:

    • Maddrey’s discriminant function
    • Glasgow score
    • Lille score (assess response to corticosteroids after 1wk)

    Treatment:

    • Immediate and lifetime abstinence from alcohol
    • Trental 400mg p.o. t.i.d.
    • Prednisolone 40mg p.o. daily (controversial, some benefit in subgroup with Maddrey > 32)
    • Ascites: Sodium restriction, diuretics
    • Encephalopathy: Lactulose, rifaximin
    • Hepatorenal syndrome: albumin, vasopressors
    • Nutritional support

    Interpretation of Liver Function Tests: 3

    Disorder Bilirubin AST/ALT Albumin PT
    Hemolysis
    Gilbert
    ↑(indirect)
    No bilirubinuria
    Acute hepatocellular necrosis ↑ALT > AST
    > 500IU

    (poor prognosis if elevated)
    Chronic liver disease

    < 300IU

    Alcoholic hepatitis

    AST:ALT > 2

    Intra- extra-hepatic cholestasis

    < 500IU

    ↑↑

    (>4x normal)

    Features of Components of Liver Function Tests: 3,4

    Features of Components of Liver Function Tests

    References:

    1. Lucey, M. R., Mathurin, P., & Morgan, T. R. (2009). Alcoholic hepatitis. The New England journal of medicine, 360(26), 2758–2769. doi:10.1056/NEJMra0805786
    2. Sohail, U., & Satapathy, S. K. (2012). Diagnosis and management of alcoholic hepatitis. Clinics in liver disease, 16(4), 717–736. doi:10.1016/j.cld.2012.08.005
    3. Kaplan MM. Chapter 302. Evaluation of Liver Function. In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL, Loscalzo J, eds. Harrison’s Principles of Internal Medicine. 18th ed. New York: McGraw-Hill; 2012.
    4. Johnston, D. E. (1999). Special considerations in interpreting liver function tests. American family physician, 59(8), 2223–2230.

    Elevated Hemidiaphragm

    CXR - PA
    CXR - Lateral

    Causes of an Elevated Hemidiaphragm

    Causes of an elevated hemidiaphragm

    References:

    1. Lavender, JP, Potts DG (1959). Differential diagnosis of elevated right diaphragmatic dome. The British journal of radiology, 32(373), 56–60.
    2. Nason, L. K., Walker, C. M., McNeeley, M. F., Burivong, W., Fligner, C. L., & Godwin, J. D. (2012). Imaging of the diaphragm: anatomy and function. Radiographics : a review publication of the Radiological Society of North America, 32(2), E51–70. doi:10.1148/rg.322115127
    3. Prokesch, R. W., Schima, W., & Herold, C. J. (1999). Transient elevation of the hemidiaphragm. The British journal of radiology, 72(859), 723–724.
    4. Burgener, F., Kormano, M. & Pudas, T. (2008). Differential diagnosis in conventional radiology. Stuttgart New York: Thieme.

    Nausea and Vomiting

    Neurologic pathways involved in pathogenesis of nausea and vomiting

    HPI:

    57yo male with a history of HTN, DM, and MI s/p stent in 2011 presenting with nausea/vomiting and hypotension. The patient had one episode of non-bloody, non-bilious emesis approximately 6 hours ago. He felt unwell so a friend checked his blood pressure which was found to be 75/50, prompting a visit to this emergency department.
    The patient’s emesis came 2 hours following a normal meal (frozen dinner), and was associated with chills/sweats but no abdominal pain. The patient had some associated shortness of breath (baselines), but no chest pain, arm or jaw pain, or palpitations.

    He states that these symptoms are unlike what he experienced during his MI. He reported no change in bowel or urinary habits.

    PMH:

    • HTN
    • DM
    • CAD
    • MI
    • Hyperlipidemia

     PSH:

    • Stent placement (2011)
    • Right knee neuroma excision (2012)

    FH:

    • Non-contributory

     SHx:

    • No current t/e/d
    • 80 pack-year smoking history

    Meds:

    • carvedilol 6.25mg p.o. b.i.d.
    • metformin 1000mg p.o. b.i.d.
    • atorvastatin 20mg p.o. daily
    • aspirin 81mg p.o. daily

    Allergies:

    • NKDA

    Physical Exam:

    VS: T 98.4 HR 65 RR 17 BP 96/56 O2 95% 2L NC
    Gen: No acute distress, speaking in complete sentences
    HEENT: PERRL, MMM no lesions, no cervical lymphadenopathy
    CV: RRR, normal S1/S2, no murmurs, no extra heart sounds, no jugular venous distension
    Lungs: CTAB, no crackles
    Abd: +BS, soft, NT/ND, no rebound/guarding, no organomegaly
    Ext: Warm, well-perfused, peripheral pulses equal b/l, no LE edema
    Neuro: AAOx3

    Labs:

    • EKG: normal sinus rhythm, anterior lead q-waves suggestive of old infarct, no T/ST changes
    • Troponin: <0.01
    • CBC: 7.4/15.5/47/228
    • BMP: 139/5.1/107/26/8/1.19/112 (baseline creatinine 1.06 in 2/2013)

    Studies:

    • CXR: no effusion, no cardiomegaly, no focal consolidation
    • Bedside US: normal cardiac wall motion, estimated EF 40-45%, retrohepatic IVC collapses with respiration

    Assessment/Plan:

    57M hx HTN, DM, MI s/p stent presenting with nausea/vomiting x1 and hypotension. The patient’s symptoms and history were concerning for acute myocardial infarction; however, early EKG and troponins were reassuring. Additionally, the absence of characteristic physical findings that would be associated with an acute MI causing cardiogenic shock (elevated JVP, extra heart sounds, pulmonary crackles) were not present. Evidence of end-organ damage was also absent.

    Other potential causes for nausea/vomiting include SBO, however, the patient reported normal BM’s and has no history of abdominal surgery. Though occurring after a meal, a single episode of emesis without associated abdominal pain lowers suspicion for biliary disease. This patient’s emesis is most likely due to acute gastroenteritis.

    Given the evidence of hypovolemia on bedside ultrasound, the patient was bolused with a total of 1.5L NS and noted symptomatic improvement as well recovery of blood pressure.

    Differential Diagnosis of Nausea/Vomiting: 1, 2

    A System for Nausea/Vomiting

    Pathophysiology: 3, 4, 5

    • Nausea: Sensation associated with increased gastrointestinal motility (tachygastria).
    • Vomiting:
      • Chemoreceptor trigger zone (area postrema of 4th ventricle): sensitive to drugs/toxins (emetics, radiation), neurotransmitters. Located outside BBB.
      • Nucleus tractus solitaries (medulla): pattern generator for vomiting, receives vagal input from GI tract and nociceptive stimuli from peripheral nervous system – transmits to hypothalamus, limbic system and cortex. Stimulated by tickling the back of the throat, gastric distention, and vestibular input.

    Important history/physical associations: 4

    • Abdominal pain: suggests organic disease, affected organ dependent on location of pain. (See figure)
    • Abdominal distension: suggests bowel obstruction.
    • Heartburn: suggests GERD.
    • Vertigo/nystagmus: suggests vestibular etiology.
    • Positional/projectile: suggests neurogenic etiology.

    Differential Diagnosis of Abdominal Pain By Location:

    Abdominal Pain by Location

    References:

    1. Scorza, K., Williams, A., Phillips, J. D., & Shaw, J. (2007). Evaluation of nausea and vomiting. American family physician, 76(1), 76–84.
    2. Bork S, Ditkoff J, Hang BS. Chapter 75. Nausea and Vomiting. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide. 7th ed. New York: McGraw-Hill; 2011. http://www.accessmedicine.com/content.aspx?aID=6360091. Accessed June 15, 2013.
    3. Koch, K. L., Stern, R. M., Vasey, M. W., Seaton, J. F., Demers, L. M., & Harrison, T. S. (1990). Neuroendocrine and gastric myoelectrical responses to illusory self-motion in humans. The American journal of physiology, 258(2 Pt 1), E304–10.
    4. Longstreth, G. F. Approach to the adult with nausea and vomiting. In: UpToDate, Basow, DS (Ed), UpToDate, Waltham, MA, 2013.
    5. Costanzo, L. (2011). Physiology. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins.
    6. Patanwala, A. E., Amini, R., Hays, D. P., & Rosen, P. (2010). Antiemetic therapy for nausea and vomiting in the emergency department. The Journal of emergency medicine, 39(3), 330–336. doi:10.1016/j.jemermed.2009.08.060

    Small Bowel Obstruction

    Dilated loops of small bowelCC:

    Consultation for bowel obstruction

    HPI:

    The patient is a 40yo male with a history of alcohol abuse, and seizure disorder secondary to traumatic brain injury who was admitted to this hospital 4d ago after an altercation with law enforcement officials. On arrival, the patient was reported to be acutely intoxicated with ecchymosis and bleeding from left lateral/posterior head and ear. No other significant injuries were found and the patient underwent CT imaging of head and c-spine, with notable findings of left occipital epidural hematoma, subarachnoid hemorrhage, but no significant midline shift. Neurosurgery was consulted and no emergent surgical intervention was required, the patient underwent serial imaging to monitor the bleed which was found to be stable and the patient slowly returned to baseline mental status.

    On HOD4, the patient developed nausea/vomiting and abdominal pain, a nasogastric tube was placed with feculent output. CT abdomen/pelvis showed high grade SBO and possible mesenteric ischemia/infarct, and general surgery was consulted for further evaluation. The patient reported experiencing some abdominal pain since the altercation, but could not recall if he was hit in the abdomen.

    PMH:

    • Alcohol abuse
    • Seizure disorder

    PSH:

    • Tibia fracture
    • No prior abdominal surgery

    FH:

    • Non-contributory

    SHx:

    • Current alcohol, marijuana use, no tobacco use
    • History of homelessness

    Medications:

    • Norco PRN
    • Ativan PRN
    • LISS, SQH, Thiamine
    • NKDA

    Physical Exam:

    • VS:  T 99.5°F    HR 108    RR 16    BP 128/82    O2 99% RA
    • Gen: NAD
    • HEENT: PERRL, EOMI, sclera clear, anicteric
    • CV: RRR, normal S1/S2
    • Lungs: CTAB
    • Abd: Distended, diffuse tenderness to palpation, no rebound tenderness, no ecchymoses or signs of trauma
    • Ext: Warm, well-perfused
    • Neuro: AAOx4, appropriate

    Assessment/Plan:

    40M w/hx alcohol abuse, TBI and seizure disorder, presented initially with evidence of head trauma which was stabilized. However, the development of abdominal pain, N/V, and finding of distension on exam associated with copious output of feculent material from NGT suggests bowel obstruction. This patient has no history of abdominal surgeries to suggest adhesions as a possible cause. Though the patient cannot recall any abdominal trauma, and there was no e/o trauma on exam, findings on CT abdomen/pelvis are suggestive of traumatic cause (hematoma causing obstruction or ischemia resulting from mesenteric injury). The patient was monitored for several days, continuing NGT to suction and with serial abdominal films. However, abdominal pain persisted, abdominal radiographs showed worsening obstruction and the patient developed leukocytosis and on HOD7 the patient was taken to the OR for exploratory laparotomy. Upon entering the peritoneal cavity, there was obvious blood and very distended small bowel which was run distally with finding of a mesenteric laceration in the distal ileum which was walled off by omentum. Additionally, a grade 2 splenic laceration was found. Ultimately, a small bowel resection with primary anastomosis along with a repair of the splenic laceration was performed.

    Imaging:

    CT abdomen/pelvis

    CT abdomen/pelvis

    Moderate abdominal and pelvic ascites which has Hounsfield unit attenuation is greater than simple fluid suggestive of blood products.

    CT abdomen/pelvis

    CT abdomen/pelvis

    Fluid dilated small bowel

    CT abdomen/pelvis

    CT abdomen/pelvis

    Complex transition point in the central mid abdomen.
    Segment of bowel at the transition point has circumferential mural thickening and surrounding complex attenuation mesenteric fluid and mesenteric stranding.

    Abdominal X-Ray

    Abdominal X-Ray

    Small bowel distention
    Nasogastric tube is seen coiled in the gastric fundus

    CT Head

    CT Head

    Left occipital extracranial soft tissue hematoma
    Left occipital epidural hematoma subjacent to the fracture site in addition to subarachnoid hemorrhage within the sulci of the left temporal lobe and interpeduncular cistern
    Extra-axial fluid collection along the right frontal convexity, tracking down the anterior falx, compatible with a subdural hematoma

    Differential Diagnosis for bowel obstruction: 1, 2, 3

    A System for Bowel Obstruction

    Types of Abdominal Pain: 4

    Types of Abdominal Pain

    References:

    1. Kulaylat MN, Doerr RJ. Small bowel obstruction. In: Holzheimer RG, Mannick JA, editors. Surgical Treatment: Evidence-Based and Problem-Oriented. Munich: Zuckschwerdt; 2001. Available from: http://www.ncbi.nlm.nih.gov/books/NBK6873/
    2. Jackson, P. G., & Raiji, M. T. (2011). Evaluation and management of intestinal obstruction. American family physician, 83(2), 159–165.
    3. Maung, A. A., Johnson, D. C., Piper, G. L., Barbosa, R. R., Rowell, S. E., Bokhari, F., Collins, J. N., et al. (2012). Evaluation and management of small-bowel obstruction. Journal of Trauma and Acute Care Surgery, 73, S362–S369. doi:10.1097/TA.0b013e31827019de
    4. Stabile, Bruce. “The Acute Abdomen.” Chairman’s Hour. Harbor UCLA Department of Surgery Student Lecture Series. 5/17/13. Lecture.

    Abdominal Wall Hernias

    Inguinal hernia CTHPI:

    23M w/no known medical history presenting with abdominal “ball” x10d. Patient denies pain, and is tolerating regular diet w/o N/V. Reports lifting weights.

    PMH/PSH/FHx/SHx:

    None, non-contributory, no t/e/d.

    Meds:

    Acetaminophen, NKDA

    PE:

    • VS:     T N/A      HR 86     RR 18       BP 116/64      O2 N/A
    • Gen: Well-appearing young male, no acute distress
    • HEENT: PERRL, MMM no lesions
    • CV: RRR, normal S1/S2, no murmurs
    • Lungs: CTAB, no crackles/wheezes
    • Abd: +BS, soft, NT/ND, 3cm bulge in right inguinal region with valsalva, above inguinal ligament, ~7cm lateral to symphysis, non-tender, reduces spontaneously after valsalva GU: uncircumcised penis, testes descended b/l, normal size, non-tender, no herniation through inguinal canal palpated with valsalva
    • Ext: Warm, well-perfused, 2+ peripheral pulses
    • Neuro: Alert and oriented, appropriate

    Assessment/Plan:

    23M ċ inguinal hernia, currently asymptomatic with no evidence of incarceration/strangulation. Recommend follow-up at city hospital for evaluation and possible surgical repair. Advised to refrain from strenuous activity, heavy lifting.

    Physical Examination Techniques: 1

    Physical Examination Techniques

    • Observation: Best performed with patient standing and physician seated on a stool facing the patient
    • Palpation: place hand over patient’s groin (see figure), with two fingers each superior and inferior to the inguinal ligament. Have the patient cough and feel for a palpable bulge or impulse.
    • GU: With a finger in the inguinal canal, bulges felt against the side of the examining finger are direct hernias, while those felt at the tip of the finger are indirect.

    Types of Abdominal Wall Hernias: 2

    Types of abdominal wall hernias

    Name Location Etiology/Epidemiology
    1. Umbilical Linea alba through weakened umbilical ring.Paraumbilical hernias through linea alba in the region of the umbilicus. Congenital or acquired due to increased intra-abdominal pressure (obesity, pregnancy, ascites, PD)
    2. Epigastric Linea alba between umbilicus and xiphoid process Congenital weakness of linea alba (lack of decussating fibers)
    3. Spigelian Semilunar line: along the lateral borders of rectus abdominus. Herniation typically occurs caudally (below arcuate line) due to absence of posterior rectus sheath.
    4. Incisional Site of prior incision Poor fascial healing possibly due to: infection (increased risk in wound dehiscence), obesity, smoking, immunosuppression excess wound tension, CT disorders.
    5. Inguinal Indirect: internal (deep) inguinal ring, lateral to inferior epigastric vessels.Direct: external (superficial) inguinal ring, medial to inferior epigastric vessels. Indirect > direct.
    6. Femoral Inferior to the inguinal ligament, through empty space medial to femoral sheath. F > M, increased likelihood of incarceration/strangulation (40%)
    7. Lumbar 3 Arise in two anatomical triangles:Superior lumbar triangle – lateral border internal oblique, medial border erector spinae, superior border 12thrib.Inferior lumbar triangle – lateral border external oblique, medial border latissimus dorsi, inferior border iliac crest. (See figure) Associated with surgery (incisional), typically urologic.
    8. Obturator Protrusion of peritoneal sac through obturator foramen. Rare, occur primarily in elderly women (high predisposition for incarceration).

    Locations of Abdominal Wall Hernias:

    Locations of abdominal wall hernias

    Layers of the Anterior Abdominal Wall:

    abdominal_wall

    Differential diagnosis for groin masses: 4

    Category Inguinal 5 Scrotal 6 Vulvar 7 Perineal 8
    Vascular Varicocele extension Varicocele Vulvar varicocity

    Hemangioma
    Infectious, Inflammatory Lymphadenopathy
    Abscess
    Inflammatory joint process (hip, related bursae)
    Thrombophlebitis
    Epididymitis
    Epididymo-orchitis
    Condyloma
    Molluscum
    Bartholin’s cyst
    Neoplastic Benign (lipoma)
    Lymph node metastatsis
    Testicular malignancy Malignant skin lesions Soft-tissue malignancy
    Anal SCC
    Rectal GIST
    Metastasis (commonly anorectal, prostatic)
    Congenital, Anatomic Hernia
    Testis (undescended, retracted)
    Epididymal cyst
    Spermatocele
    Hydrocele
    Embryological remnants (mucocele)
    Traumatic Hematoma
    Aneurysm (complication of catheterization)
    Hematoma Hematoma

    Locations of Groin Masses: 9

    Locations of groin masses

    References:

    1. Amerson JR. Inguinal Canal and Hernia Examination. In: Walker HK, Hall WD, Hurst JW, editors. Clinical Methods: The History, Physical, and Laboratory Examinations. 3rd edition. Boston: Butterworths; 1990. Chapter 96. Available from: http://www.ncbi.nlm.nih.gov/books/NBK423/
    2. Aguirre, D. A., Casola, G., & Sirlin, C. (2004). Abdominal Wall Hernias: MDCT Findings. American Journal of Roentgenology, 183(3), 681–690. doi:10.2214/ajr.183.3.1830681
    3. Guillem, P., Czarnecki, E., Duval, G., Bounoua, F., & Fontaine, C. (2002). Lumbar hernia: anatomical route assessed by computed tomography. Surgical and radiologic anatomy : SRA, 24(1), 53–56.
    4. Roberts, J. R., & Hedges, J. R. (2010). Clinical procedures in emergency medicine. (5th ed., Vol. section 7, p. Ch. 44). W B Saunders Co. Retrieved from http://www.mdconsult.com/books/page.do?eid=4-u1.0-B978-1-4160-3623-4.00044-4
    5. Shadbolt, C. L., Heinze, S. B., & Dietrich, R. B. (2001). Imaging of groin masses: inguinal anatomy and pathologic conditions revisited. Radiographics : a review publication of the Radiological Society of North America, Inc, 21 Spec No, S261–71.
    6. Eyre, RC. Evaluation of nonacute scrotal pathology in adult men. In: UpToDate, Rose, BD (Ed), UpToDate, Waltham, MA, 2013.
    7. Foster, D. C. (2002). Vulvar disease. Obstetrics and gynecology, 100(1), 145–163.
    8. Tappouni, R. F., Sarwani, N. I., Tice, J. G., & Chamarthi, S. (2011). Imaging of unusual perineal masses. American Journal of Roentgenology, 196(4), W412–20. doi:10.2214/AJR.10.4728
    9. Collins, R. (2008). Differential diagnosis in primary care. Philadelphia: Lippincott Williams & Wilkins.