07 January 2009

Shall we play a game?


A seventy-six year-old man presented with a fever and the sudden onset of abdominal pain. He was tachycardic and hypotensive, thought not terribly so. His abdominal exam was notable for lower abdominal tenderness which did not lateralize; there was guarding present but no rebound tenderness, with an absence of bowel sounds. Multiple trauma patients were occupying the CT scanner and would be expected to do so for the foreseeable future. The surgeon on call was contacted and was reluctant to come see the patient without a CT scan. What finding is visible on the above plain film of the abdomen that might convince him to expedite his evaluation of the patient?

Please put your answers in the comments. First correct answer wins a genuine karmic invisishirt! Scanman and other radiologists are excluded from the competition, but may email me directly to establish their superiority. Just for the record, I did pick this finding up myself. (and as they say, if the ER doc can see it...)

28 comments:

  1. While reading X rays is not something anybody should trust me to do, and the patient was complaining of lower abdominal pain, the right side of the film (left side of the patient) seems to show intestines, or something extending up into the thoracic space. Hernia? If what I am seeing is real, given my lack of X ray knowledge, wouldn't the patient also have significant respiratory distress?

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  2. Patient appears to have dilated loops of small bowel with a J point transition. My guess is SBO.

    Another abnormality is, that the right renal artery appears to have air in it??? or am I seeing things. I would want to review that finding with a radiologist.

    Otherwise, it appears to be a SBO.

    How distended is the patient?

    Last BM?

    Passing any flatulence?

    H/O SBO or previous abdominal surgeries?

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  3. pneumatosis intestinale

    dead gut

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  4. p.s. i'm an er doc

    ,,,probably not someone who should wait for a ct scan

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  5. Yeah- I think there is air where it should not be - on the right side within the intestinal wall.

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  6. Spare tire sign -- sigmoid volvulus

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  7. I saw it before I read any other comments...air surrounding the bowel. He has a perforation somewhere and a non functional bowel. Could be a diverticuli (?) but with hypotension he should also have a lactate as a sepsis screen, get fluids going STAT and get that surgeon in there!
    I am an Internist.

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  8. There is defintely air where there shouldn't be. As a (sometimes cocky but definitely not trained to read roentgenographs) paramedic, I'll guess gas. But I'd want someone with more training to look at it before putting them in triage.

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  9. At first glance, the right side of the colon looked awfully well defined; much more so than would usually be seen. Yep, there's air in the wall of that thar intestine. I'm pretty sure this is Not Good (pneumatosis intestinale indeed) and I would hope that the sturgeon would be sufficiently impressed to get in there without insisting on the CT.

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  10. Uh, you usually can't see the bowel that distinctly in an x-ray, so I'm guessing the patient's got a big issue there?

    (Dude, I'm a purchasing agent who did six months in a film library and still can't tell if a chest film is PA or AP. If *I* can see it, surgeon better haul butt to the ER, yo.)

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  11. Totally the wrong kind of a doctor here, and willing to believe the others. But the spine looks curved side to side; is that usual?

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  12. Pneumatosis coli.

    Good pickup!

    GruntDoc

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  13. Is that a positive throckmorton sign, too??

    I'm not even in medicine, but it's a funny thing to know about.

    And my word verification is "ingst", so maybe he's all constipated from ingesting something weird like hair (bezoar).

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  14. I think he's swallowed his ipod headset. 8-)

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  15. pneumatosis intestinalis

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  16. ps: I'm a surgeon, and would certainly haul ass into the ER for this.

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  17. pneumatosis intestinalis...ER resident

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  18. This comment has been removed by the author.

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  19. For 76 his spine looks pretty bad too. Aren't there any orthopedists looking at this post? -3rd yr med student

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  20. if he were a preemie it would be necrotizing enterocolitis. In an old guy, dead gut, very bad, call somebody stat. That's all I got.
    ~your children's pediatrician

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  21. From a non-medic, and briefly lightening the mood somewhat, he appears to have a massive erection (right of patient, coming from central pelvis).

    Alternative explanation - I'm just a dirty minded student!

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  22. I see pneumatosis intestinalis and free air. Poor guy.

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  23. Just a vet - but I see free abdominal air, which in my world means cut immediately and plan for DIC from sepsis.

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  24. Chris, good spot, and you almost got it, but this is actually just a good ol' foreign body case!

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  25. New to this blog, but I'd say peritonitis due to a ruptured appendix.

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  26. so what was the answer?

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