Hollow organ perforation in blunt abdominal trauma: the role of diagnostic peritoneal lavage

Background

With recent advances in radiologic diagnostic procedures, the use of diagnostic peritoneal lavage (DPL) has markedly declined. In this study, we reviewed data to reevaluate the role of DPL in the diagnosis of hollow organ perforation in patients with blunt abdominal trauma.

Methods

Adult patients who had sustained blunt abdominal trauma and who were hemodynamically stable after initial resuscitation underwent an abdominal computed tomographic (CT) scan. Diagnostic peritoneal lavage was performed for patients who were indicated to receive nonoperative management and where hollow organ perforation could not be ruled out.

Results

During a 60-month period, 64 patients who had received abdominal CT scanning underwent DPL. Nineteen patients were diagnosed as having a positive DPL based on cell count ratio of 1 or higher. There were 4 patients who sustained small bowel perforation. The sensitivity and specificity of the cell count ratio for a hollow organ perforation in this study were 100% and 75%, respectively. No missed hollow organ perforations were detected.

Conclusion

For patients with blunt abdominal trauma and hemoperitoneum who plan to receive nonoperative management, DPL is still a useful tool to exclude hollow organ perforation that is undetected by CT.     

Clinician vs mathematical statistical models: which is better at predicting an abnormal chest radiograph finding in injured patients?

Objective

The purpose of this study was to determine if statistical models for prediction of chest injuries would outperform the clinician's (MD) ability to identify injured patients at risk for a thoracic injury diagnosed by chest radiograph (CXR).

Design

A prospective observational study was done during a 12-month period.

Setting

The study was conducted in a level I trauma center.

Patients

Injured patients meeting trauma team activation criteria were enrolled to the study.

Interventions

Physical examination findings by a clinician were interpreted and CXR was performed.

Outcome measures

The accuracy of 2 mathematical models is compared against the accuracy of clinician's clinical judgment in predicting an injury by CXR. Two newly constructed multivariate models, binary logistic regression (LR) and classification and regression tree (CaRT) analysis, are compared to previously published data of clinician clinical assessment of probability of thoracic injury identified by CXR.

Results

Data for 757 patients were analyzed. Classification and regression tree analysis developed a stepwise decision tree to determine which signs/symptoms were indicative of an abnormal CXR finding.The sensitivity (CaRT, 36.6%; LR, 36.3%; MD, 58.7%), specificity (CaRT, 98.3%; LR, 98.2%; MD, 96.4%), and error rates (CaRT, 0.93; LR, 0.94; MD, 0.82) show that the mathematical decision aids are less sensitive and risk more misclassification compared to clinician judgment in predicting an injury by CXR.

Conclusion

Clinician judgment was superior to mathematical decision aids for predicting an abnormal CXR finding in injured patients with chest trauma.     

Effect of an automated chest radiograph at triage protocol on time to antibiotics in patients admitted with pneumonia

Objective

We derived and tested a protocol to automatically order a chest radiograph (CXR) at emergency department triage for patients with signs and symptoms of pneumonia to reduce time to antibiotics.

Methods

We derived a protocol using a retrospective study of admitted adult patients with pneumonia then prospectively tested the protocol on time to antibiotics. The protocol included patients with a chief complaint of chest pain, shortness of breath, upper respiratory tract infection, hemoptysis, fever, and cough. Of those, patients 50 years or older with any vital sign abnormality and patients younger than 50 with a comorbidity of immunocompromise, cancer, diabetes, transplant, or chronic alcoholism had a CXR ordered automatically.

Results

Although the protocol was only 35% (95% confidence interval, 28%-43%) sensitive in identifying patients admitted with pneumonia, time to antibiotics (in hours) (3.4 vs 4.2, P = .01) and time to CXR (3.0 vs 2.0, P = .01) for patients admitted with pneumonia were lower during the study period.

Conclusion

Automated CXR at triage reduces time to antibiotics in patients admitted with pneumonia.     

High discordance of chest x-ray and computed tomography for detection of pulmonary opacities in ED patients: implications for diagnosing pneumonia

Objective

To evaluate the diagnostic performance of chest x-ray (CXR) compared to computed tomography (CT) for detection of pulmonary opacities in adult emergency department (ED) patients.

Methods

We conducted an observational cross-sectional study of adult patients presenting to 12 EDs in the United States from July 1, 2003, through November 30, 2006, who underwent both CXR and chest CT for routine clinical care. CXRs and CT scans performed on the same patient were matched. CXRs and CT scans were interpreted by attending radiologists and classified as containing pulmonary opacities if the final radiologist report noted opacity, infiltrate, consolidation, pneumonia, or bronchopneumonia. Using CT as a criterion standard, the diagnostic test characteristics of CXR to detect pulmonary opacities were calculated.

Results

The study cohort included 3423 patients. Shortness of breath, chest pain and cough were the most common complaints, with 96.1% of subjects reporting at least one of these symptoms. Pulmonary opacities were visualized on 309 (9.0%) CXRs and 191 (5.6 %) CT scans. CXR test characteristics for detection of pulmonary opacities included: sensitivity 43.5% (95% CI, 36.4%-50.8%); specificity 93.0% (95% CI, 92.1%-93.9%); positive predictive value 26.9% (95% CI, 22.1%-32.2%); and negative predictive value 96.5% (95% CI, 95.8%-97.1%).

Conclusion

In this multicenter cohort of adult ED patients with acute cardiopulmonary symptoms, CXR demonstrated poor sensitivity and positive predictive value for detecting pulmonary opacities. Reliance on CXR to identify pneumonia may lead to significant rates of misdiagnosis.     

Left brachiocephalic vein perforation: computed tomographic features and treatment considerations

Objective

To report the clinical and computed tomographic findings of 5 cases of left brachiocephalic vein perforation (LBCVP).

Methods

The clinical and imaging features of 5 patients with LBCVP (1 woman, 4 men; mean age, 57.6 years) encountered over the last 2 decades were reviewed.

Results

Etiologies included left jugular central catheter penetration in 2 patients, blunt trauma in 2, and idiopathic in 1. All patients manifested acute chest pain with a widened mediastinum on chest radiographs. Characteristic computed tomographic features included a cord-like hematoma along the course of the left brachiocephalic vein associated with a left upper anterior mediastinal hematoma (AMH). Three clinically stable patients with AMH smaller than 5 cm convalesced after conservative treatment and 2 clinically unstable patients with AMH bigger than 7 cm recovered well after surgery.

Conclusions

Computed tomography is helpful in diagnosing LBCVP. Under close surveillance, patients with stable LBCVP with AMH smaller than 5 cm may be managed conservatively. However, emergency surgery is warranted if there are any signs of instability.     

Discordance in interpretation of chest radiographs between pediatric intensivists and a radiologist: Impact on patient management

Purpose

When radiologists are not available, chest radiographs (CXRs) of pediatric intensive care unit (PICU) patients are commonly interpreted by pediatric intensivists. We prospectively investigated the frequency of errors in CXR interpretation by pediatric intensivists and their impact on patient management.

Materials and Methods

Chest radiographs of PICU patients were evaluated by 5 pediatric intensivists then by a pediatric radiologist (the “gold standard”). If the interpretation of the radiologist and intensivist differed, an independent intensivist determined whether a management change took place. A pediatric pulmonologist determined how many intensivist interpretations were different from the radiologist's interpretations.

Results

Seven hundred twenty-eight radiographic findings were identified by the radiologist in 460 CXRs. There were 33 interpretation errors by the intensivists (4.5% of the findings in 7.1% of the CXRs). Only 3/33 error corrections (0.45% of the findings in 0.7% of the CXRs) resulted in change in patient management.

Conclusions

Errors in interpretation of CXRs by pediatric intensivists were common but less than that in other series, probably because of education of the pediatric intensivists through daily rounds with the radiologist. Although interpretation errors that affected patient management were rare, their clinical importance supports the growing practice of 24/7 remote radiograph reading by radiologists.     

Chest radiography after endotracheal tube placement: is it necessary or not?

Purpose

The aim of this study was to evaluate the necessity of chest x-ray (CXR) in detecting the endotracheal tube (ETT) misplacement after the intubation.

Basic procedures

In this cross-sectional study, we took a CXR after confirming the ETT placement by physical examination. The distance between the tip of the ETT and carina was then evaluated and graded as satisfactory if it was more than 2 cm.

Main findings

During the study period, 381 patients were intubated in the emergency department (ED). According to the CXR findings, the distance between the ETT and carina was more than 2 cm in 336 patients (88.2%), whereas it was less than 2 cm in 45 patients (11.8%). Fourteen ETTs (3.6%) were judged to be too low with 6 (1.5%) of these being right bronchus intubations. One patient had a CXR confirming left bronchial intubation.

Principal conclusions

Although ED intubations have high success rate, the complications of inappropriate intubations are highly remarkable that postintubation CXR remains a necessary step to minimize the misplacement of the tube.     

Contrast enhanced ultrasound vs chest X-ray to determine correct central venous catheter position

Purposes

We aimed to analyze the diagnostic accuracy of contrast enhanced ultrasonography (CEUS), compared with chest x-ray (CXR), in the detection of correct central venous line (CVL) placement. Our hypothesis was to verify whether CEUS could substitute CXR as a reference standard for correct placement of CVL or function as a triage test to limit the execution of CXR only for selected patients.

Basic Procedures

CEUS was carried out in 71 non consecutive patients to verify the correct positioning of a central venous line. Sensitivity, specificity, positive and negative predictive values, and likelihood ratios of CEUS compared to CXR, with their respective 95% confidence interval (CI), were calculated.

Main Findings

CXR identified 6 CVL misplacements (8,4%, CI 95% 3,2%-18%). Four of these were intravascular and 2 in the right atrium. CEUS identified only 3 misplacements, of which 1 was intravascular and 2 intracardiac. Using CXR as a reference standard, and considering intravascular and intracardiac malpositioning altogether, the sensitivity, specificity, and positive and negative likelihood ratio of CEUS were 33% (95% CI, 0%-71%), 98% (95% CI, 95%-100%), 21%, 7%, 0%, and 68%, respectively. The negative and positive predictive values were 94% (95% CI, 89%-100%) and 67% (95% CI, 13%-100%).

Principal conclusions

CEUS can't substitute CXR, or become a triage test in selected patients, in evaluating the correct tip position after CVL placement.     

Evaluation of lung ultrasound for the diagnosis of pneumonia in the ED

Objectives

The aim of this study is to assess the ability of bedside lung ultrasound (US) to confirm clinical suspicion of pneumonia and the feasibility of its integration in common emergency department (ED) clinical practice.

Methods

In this study we performed lung US in adult patients admitted in our ED with a suspected pneumonia.Subsequently, a chest radiograph (CXR) was carried out for each patient. A thoracic computed tomographic (CT) scan was made in patients with a positive lung US and a negative CXR. In patients with confirmed pneumonia, we performed a follow-up after 10 days to evaluate clinical conditions after antibiotic therapy.

Results

We studied 49 patients: pneumonia was confirmed in 32 cases (65.3%). In this group we had 31 (96.9%) positive lung US and 24 (75%) positive CXR. In 8 (25%) cases, lung US was positive with a negative CXR. In this group, CT scan always confirmed the US results. In one case, US was negative and CXR positive. Follow-up turned out to be always consistent with the diagnosis.

Conclusion

Considering that lung US is a bedside, reliable, rapid, and noninvasive technique, these results suggest it could have a significant role in the diagnostic workup of pneumonia in the ED, even if no sensitivity nor specificity can be inferred from this study because the real gold standard is CT, which could not be performed in all patients.     

Provider perceptions concerning use of chest x-ray studies in adult blunt trauma assessments

Background

Although they infrequently lead to management changing diagnoses, chest x-rays (CXRs) are the most commonly ordered imaging study in blunt trauma evaluation.

Objectives

To determine: 1) the reasons physicians order chest X-ray studies (CXRs) in blunt trauma assessments; 2) what injuries they expect CXRs to reveal; and 3) whether physicians can accurately predict low likelihood of injury on CXR.

Methods

At a Level I Trauma Center, we asked resident and attending physicians treating adult blunt trauma patients: 1) the primary reason(s) for getting CXRs; 2) what, if any, significant intrathoracic injuries (SITI) they expected CXRs to reveal; and 3) the likelihood of these injuries. An expert panel defined SITI as two or more rib fractures, sternal fracture, pulmonary contusion, pneumothorax, hemothorax, or aortic injury on official CXR readings.

Results

There were 484 patient encounters analyzed—65% of participating physicians were residents and 35% were attendings; 16 (3.3%) patients had SITI. The most common reasons for ordering CXRs were: “enough concern for significant injury” (62.9%) and belief that CXR is a “standard part of trauma work-up” (24.8%). Residents were more likely than attendings to cite “standard trauma work-up” (mean difference = 13.5%, p = 0.003). When physicians estimated a < 10% likelihood of SITI on CXR, 2.1% (95% confidence interval [CI] 1.0–4.1%) of patients had SITI; when they predicted a 10–25% likelihood, 5.7% (95% CI 1.2–15.7%) had SITI; and when they predicted a > 25% likelihood, 9.1% (95% CI 3.0–20.0%) had SITI.

Conclusions

Physicians order CXRs in blunt trauma patients because they expect to find injuries and believe that CXRs are part of a “standard” work-up. Providers commonly do not expect CXRs to reveal SITI. When providers estimated low likelihood of SITI, the rate of SITI was very low.     

Oxygen Reservoir Bags Simulating Chest Pathology: A Case Series

Background

We present a series of plain chest radiographs taken in acute settings, with artifactual projections from oxygen reservoir bags. These artifacts are shown to simulate chest pathology in each case.

Objectives

The identification of artifacts on imaging prevents misdiagnosis and potential mistreatment of patients in acute settings. We highlight patterns of findings caused by the projection of oxygen reservoir bags in radiographs taken in the emergency setting.

Case Reports

We present plain chest films in 4 patients taken in the acute setting, either in the emergency department or acute admissions unit. In this case series, oxygen reservoir bags simulate pneumothoraces, lung edges, and bullous disease.

Conclusion

Artifacts on chest radiographs are potential causes of misdiagnosis and subsequent inappropriate treatment. By highlighting the patterns created by the projection of oxygen reservoir bags, emergency physicians, radiologists, and reporting radiographers will be aware of the potential problems.     

Can acute cholecystitis with gallbladder perforation be detected preoperatively by computed tomography in ED?: Correlation with clinical data and computed tomography features

Purpose

The purpose of this study is to determine which computed tomography (CT) findings and clinical data can help to diagnose gallbladder perforation in acute cholecystitis.

Materials and Methods

The medical records and CT findings of patients with surgically proven acute cholecystitis within the last recent 5 years were retrospectively reviewed and compared between 2 groups with and without gallbladder perforation.

Results

A total of 75 patients with acute cholecystitis were included in the study, and 16 patients were proven to have gallbladder perforation. Higher mortality rate was found in the perforation group (18.8% vs 1.7%; P = .029). Older age (>70 years; P = .004) and higher percentage of segmented neutrophil (>80%; P = .027) were significant clinical factors for predicting gallbladder perforation in acute cholecystitis. The significant CT signs related to gallbladder perforation included visualized gallbladder wall defect (P = .000), intramural gas (P = .043), intraluminal gas (P = .000), intraluminal membrane (P = .043), pericholecystic abscess or biloma formation (P = .009), intraperitoneal free air (P = .001), and presence of ascites in the absence of hypoalbuminemia or other intraabdominal malignancy (P = .017). In multivariate analysis, visualized gallbladder wall defect was the most significant predicting CT feature for diagnosing gallbladder perforation in acute cholecystitis.

Conclusion

Elderly patients with higher segmented neutrophil and CT signs of gallbladder wall defect associated with acute cholecystitis may have high possibility of gallbladder rupture.     

The early prognostic factors of glyphosate-surfactant intoxication

Background and Purpose

The purpose of this study was to establish an early prognostic model of patients with glyphosate-surfactant (GlySH) herbicide intoxication.

Methods

A case-control study was conducted. Data of GlySH-intoxicated patients were collected from 2 hospitals. Patients were admitted to the emergency departments (EDs) of Chang Gung Memorial Hospital from April 1996 to March 2003 and Taichung Veterans General Hospital from April 2000 to October 2003. Collected variables such as age, sex, estimated amount of ingestion, symptoms/signs including first vital signs, chest x-ray (CXR), and biochemical studies were analyzed for their role in the prognostic model of GlySH intoxication mortality. Univariate and odds ratio analyses were then performed. The prognostic model was then established by using logistic regression analysis and further stratified analysis.

Results

Fifty-eight patients (19 men and 39 women; age, 48.8 ± 15.8 years; P = .38) were enrolled in our study. Forty-one patients survived from GlySH intoxication and 17 died. After univariate analysis, 5 variables (respiratory distress needing intubation, metabolic acidosis, tachycardia, elevated creatinine (Cr) level, and hyperkalemia) were found to be highly associated with poor outcome and mortality. Then a multiple logistic regression model was established as follows: log(p/q) = −6.13 + 3.43 (abnormal CXR) + 2.53 (metabolic acidosis) + 2.55 (Cr) + 2.4 (tachycardia) + e.

Conclusion

GlySH poisoning is multiorgan toxicity. Pulmonary toxicity and renal toxicity seem to be responsible for its mortality. Metabolic acidosis, abnormal CXR, tachycardia, and elevated Cr level are useful prognostic factors for predicting GlySH mortality.     

A comparison of different diagnostic tests in the bedside evaluation of pleuritic pain in the ED

Purposes

Bedside lung ultrasound (LUS) is useful in detecting radio-occult pleural-pulmonary lesions. The aim of our study is to compare the value of LUS with other conventional routine diagnostic tools in the emergency department (ED) evaluation of patients with pleuritic pain and silent chest radiography (CXR).

Methods

Ninety patients consecutively admitted to the ED with pleuritic pain and normal CXR were retrospectively (n = 49) and prospectively (n = 41) studied. All patients were blindly examined by LUS and submitted to clinical examination and blood samples. The ability of blood tests and symptoms to predict any radio-occult pleural-pulmonary condition confirmed by conclusive image techniques and follow-up was evaluated and compared with LUS.

Results

In 57 cases, the final diagnosis was chest wall pain. The other 33 patients were diagnosed with a pleural-pulmonary condition (22 pneumonia, 2 pleuritis, 7 pulmonary embolism, 1 lung cancer, 1 pneumothorax). Lung ultrasound showed a sensitivity of 96.97% (95% confidence interval [CI], 84.68%-99.46%) and a specificity of 96.49% (95% CI, 88.08%-99.03%) in predicting radio-occult pleural-pulmonary lesions and significantly higher area under the curve (AUC) of receiver operating characteristic analysis (AUC, 0.967; 95% CI, 0.929-1.00) than d-dimer (AUC, 0.815; 95% CI, 0.720-0.911) and white blood cell count (AUC, 0.778; 95% CI, 0.678-0.858). None of the other routine tests considered or a combination between them better predicted the final diagnosis.

Conclusions

Chest radiography and blood tests may be inadequate in the diagnostic process of pleuritic pain. In case of silent CXR, LUS is critical for identifying patients with pleural-pulmonary radio-occult conditions at bedside and cannot be safely replaced by other conventional methods.     

Biomechanical modeling of the lateral decubitus posture during corrective scoliosis surgery

Background

Patient prone positioning in scoliosis surgeries modifies the spinal curves prior to instrumentation. However, the biomechanical effects of the lateral decubitus posture, used in anterior approaches and minimally invasive techniques, have not yet been investigated. The objectives were to develop and validate a finite element model simulating the spinal changes resulting from this positioning.

Methods

The 3D pre-op reconstructed geometries of six adolescent patients with idiopathic scoliosis were used to develop personalized finite element models of the spine, which integrated a three-step method simulating the lateral posture. Clinical indices were measured on pre- and intra-operative radiographs to validate the finite element model.

Findings

The major Cobb angle and apical vertebral translation were reduced by 44% and 37% respectively between the pre- and intra-op postures. Using appropriately oriented gravity forces and boundary conditions, the finite element model simulations represented adequately these changes, with average differences of 4° for the major Cobb angle and 4 mm for the apical vertebral translation with the radiographic values.

Interpretation

Lateral decubitus positioning significantly reduces the spinal deformities prior to instrumentation, as demonstrated by the finite element model. This study is a first step in the development of a modeling tool for the optimal adjustments of intra-operative positioning, which remains to be further investigated with complementary clinical studies.     

Pneumomediastinum,Pneumothorax, and Subcutaneous Emphysema Caused by Colonoscopic Perforation: A Report of Two Cases

Background

Although colonoscopy is generally a safe procedure, lethal complications can occur. Colonoscopic perforation is one of the most serious complications, and it can present with various clinical symptoms and signs. Aggravating abdominal pain and free air on simple radiography are representative clinical manifestations of colonoscopic perforation. However, unusual symptoms and signs, such as dyspnea and subcutaneous emphysema, which are less likely to be related with complicating colonoscopy, may obscure correct clinical diagnosis. We present two cases of pneumomediastinum, pneumothorax, and subcutaneous emphysema caused by colonoscopic perforation.

Thoracic impedance vs chest radiograph to diagnose acute pulmonary edema in the ED

Objective

We sought to investigate the relationship between thoracic impedance (Zo) and pulmonary edema on chest radiography in patients presenting to the emergency department (ED) with signs and symptoms of acute decompensated heart failure (ADHF).

Design

This was a prospective, blinded convenience sample of patients with signs and symptoms of ADHF who underwent measurement of Zo with concomitant chest radiography. Attending physicians blinded to the Zo values interpreted the radiographs, categorizing the severity of pulmonary edema as normal (NL), cephalization (CZ), interstitial edema (IE), or alveolar edema (AE). Intergroup comparisons were analyzed with a 2-way analysis of variance (ANOVA), with P < .05 considered statistically significant and reported using 95% confidence intervals (CIs).

Setting

We enrolled patients (≥18 years) presenting to a tertiary care medical center ED with signs and symptoms consistent with ADHF.

Results

A total of 203 patients were enrolled, with 27 (14%) excluded because of coexisting pulmonary diseases. The mean Zo values were inversely related to the 4 varying degrees of radiographic pulmonary vascular congestion as follows: NL, 25.6 (95% CI, 22.9-28.3); CZ, 20.8 (95% CI, 18.1-23.5); IE, 18.0 (95% CI, 16.3-19.7); and with AE, 14.5 (95% CI, 12.8-16.2) (ANOVA, P < .04). A Zo less than 19.0 ohms had 90% sensitivity and 94% specificity (likelihood ratio [LR], − 0.1; LR + 15) for identifying radiographic findings consistent with pulmonary edema. Females had an increased mean Zo value compared to males (P < .03).

Conclusion

The Zo value obtained via thoracic bioimpedance monitoring accurately predicts the presence and severity of pulmonary edema found on initial chest radiograph in patients suspected of ADHF.     

Computed tomography is not justified in every pediatric blunt trauma patient with a suspicious mechanism of injury

Objective

Computed tomography (CT) has become an important tool for the diagnosis of intra-abdominal and chest injuries in patients with blunt trauma. The role of CT in conscious asymptomatic patients with a suspicious mechanism of injury remains controversial. This controversy intensifies in the management of pediatric blunt trauma patients, who are much more susceptible to radiation exposure. The objective of this study was to evaluate the role of abdominal and chest CT imaging in asymptomatic pediatric patients with a suspicious mechanism of injury.

Methods

Forty-two pediatric patients up to 15 years old were prospectively enrolled. All patients presented with a suspicious mechanism of blunt trauma and multisystem injury. They were neurologically intact and had no signs of injury to the abdomen or chest. Patients underwent CT imaging of the chest and abdomen as part of the initial evaluation.

Results

Thirty-one patients (74%) had a normal CT scan. Two patients of 11 with an abnormal CT scan required a change in management and were referred for observation in the Intensive Care Unit. None of the patients required surgical intervention.

Conclusion

The routine use of CT in asymptomatic pediatric patients with a suspicious mechanism of blunt trauma injury is not justified.     

Torsion of a Wandering Spleen Treated with Partial Splenectomy and Splenopexy

Background

Wandering spleen is a rare and unusual entity, characterized by excessive mobility and displacement of the organ from its normal position. This happens due to congenital or acquired anomalies leading to the lack of the spleen’s suspensory ligaments. Clinical presentation is variable; acute abdominal pain may occur when persistent torsion of the splenic pedicle results in splenic infarction. Ultrasonography, computed tomography, and magnetic resonance imaging are modalities that may be used in diagnosis. The treatment of choice is surgery, with splenectomy or splenopexy, the latter being preferred.

Case Report

The patient was a 38-year-old woman with a 10-day history of left-sided abdominal pain. Imaging demonstrated a wandering spleen with partial infarction of the inferior pole. An open partial splenectomy with splenopexy of the remaining spleen was performed with the use of an absorbable mesh sutured to the abdominal wall and stomach. Her recovery was uneventful and on follow-up she had no signs of recurrence or complications.

Conclusion

Wandering spleen should be considered in cases of acute abdominal pain, and surgery is the treatment of choice, with the goal of preservation of the organ whenever possible.     

Spontaneous Perforation of Acalculous Gall Bladder Presenting as Acute Abdomen

Background

Acute abdominal pain is commonly encountered in the emergency department (ED), but a diagnosis of gall bladder perforation (GBP) is rarely considered in the absence of predisposing factors.

Objectives

This article will highlight the risk factors, diagnosis, and management of GBP, a rare but potentially life-threatening biliary pathology.

Case Report

A 73-year-old diabetic man presented to the ED with a 12-h history of severe upper abdominal pain. He was hemodynamically stable, but abdominal examination showed distention, guarding, and diffuse tenderness. Abdominal X-ray study showed mildly distended small bowel loops without any air-fluid levels. Abdominal sonography revealed mild ascites and pericholecystic fluid collection but no gall bladder calculi. Laboratory reports documented a white blood cell count of 13,700/mm³ and elevated serum amylase of 484 IU/L. A contrast-enhanced computed tomography (CT) scan of the abdomen suggested discontinuity of the gall bladder wall along with fluid accumulation in the pericholecystic, perihepatic, right subphrenic, and right paracolic spaces. In view of the possibility of spontaneous GBP developing as a complication of acute acalculous cholecystitis, laparotomy was planned. At surgery, several liters of bile-stained peritoneal fluid were aspirated and inspection of the gall bladder revealed a perforation at the fundus. After cholecystectomy, the patient had an uneventful recovery.

Conclusion

The diagnosis of spontaneous gall bladder perforation should be considered in elderly patients presenting to the ED with symptoms and signs of peritonitis even in the absence of pre-existing gall bladder disease. Abdominal CT scan is an invaluable tool for the diagnosis, and early surgical intervention is usually life-saving.