Diagnosis: Perforated Viscus

Review of the patient's CXR revealed free air under the diaphragm. The patient denied having any history of diverticulitis, gastroesophageal reflux disease, peptic ulcer disease, heartburn symptoms, prior gastrointestinal bleeding or constipation. 

Surgery was urgently consulted and the patient consented and taken to the OR where she was found to have a single punctate perforation located at the gastric antrum just proximal to pylorus. An EGD was then performed which revealed a full-thickness gastric perforation with fluid and air escaping from the stomach into the abdomen. The perforation was closed by primary repair followed by abdominal washout and the patient did well post-operatively. 

Perforated Viscus

Epidemiology 

• Incidence increases with age
• A history of peptic ulcer disease or diverticular disease is common 

Etiology

• More often a duodenal ulcer that erodes through the serosa
• Colonic diverticula, large bowel, and gallbladder perforations are rare
• Spillage of bowel contents causes peritonitis 

Presentation

• Acute onset of epigastric pain 
• Vomiting in 50%
• Fever may later develop 
• Pain may localize with omental walling off of peritonitis
• Shock may be present with bleeding or sepsis 

Physical Exam

• Fever, usually low grade
• Tachycardia 
• Decreased bowel sounds
• Overall condition worsens over time
• Abdominal examination reveals diffuse guarding and rebound 
• "Washboard" abdomen in later stages

Useful Tools

• WBC usually elevated owing to peritonitis 
• Amylase may be elevated
• LFT results are variable
• Upright radiographic view reveals free air in 70-80% of cases 

Management

• IVF resuscitation
• NPO, consider NG-tube 
• Broad-spectrum antibiotics with intestinal flora coverage (gram negative, anaerobic) 

TAKE AWAY:

1. Pain is sudden and followed quickly by signs of peritonitis and shock
2. Diagnose by plain radiograph or CT scan
3. Surgical repair is necessary in conjunction with IVF resuscitation and antibiotics

References: 

Rosen's Emergency Medicine Concepts and Clinic Practice, 8th Ed, 2014, Chapter 27: Abdominal Pain by Gavin R. Budhram and Rimon N. Bengiamen

Feeling Bloated

A 63 year-old female presents with chief complaint of severe abdominal pain. The patients reports walking out of a department store this afternoon when she experienced an abrupt onset of sharp abdominal pain rated as a 10/10 that has not improved since arriving to the emergency department.

The patient describes pain involving her entire abdomen, though it seems worse in the upper half than the lower half. She denies associated nausea or vomiting but does endorse feeling bloated. The patient remembers having cereal and milk for breakfast this morning, as well as a normal bowel movement earlier today that was non-bloody.

She denies having fevers, chills, chest pain, or shortness of breath.

Exam is remarkable for diffuse abdominal tenderness in all 4 quadrants, no peritoneal signs and positive bowel sounds. 

Laboratory tests including a CBC, CMP, lipase, and urine analysis are sent and pending.

In addition, a CXR is obtained:

Can you guess the diagnosis?

Leave a comment below and tell us how you would manage this patient.

The actual diagnosis for this real-life case will be posted in 1 week. 

Diagnosis: Aortic Dissection

Review of the CTA chest revealed a type A dissection of the ascending aorta and aortic arch. The patient was taken immediately to the operating room by cardiothoracic surgery where he underwent resection and primary repair of a chronic ascending aortic dissection with partial resection of an ascending aorta and aortic arch aneurysm, and resuspension and repair of the aortic valve under cardiopulmonary bypass with deep hypothermic circulatory arrest. 

Epidemiology

• most common risk factor --> hypertension

• other risk factors: 
• male gender
• stimulant use
• age >40
• previous cardiac surgery
• bicuspid aortic valve
• aortic balloon-pump insertion
• Marfan syndrome
• Ehlers-Danlos syndrome 

• inflammatory vasculitides associated with aortic dissection: 
• Takayasu's arteritis
• Giant cell arteritis 
• Behcet's disease

• 44% of patients with Marfan syndrome develop aortic dissection and account for 5% of cases

Classification

• The Stanford classification is based on whether there is involvement of the ascending aorta
• Type A dissections involve the ascending aorta
• 62%
• more lethal
• Type B dissections do not 
• 38%
• can be managed conservatively

• Acute dissection: < 2 weeks
• Chronic dissection: > 2 weeks

                           Stanford type B aortic dissection 

Presentation

• abrupt 
• "sharp," "tearing," "ripping" chest or back pain
• diaphoresis, nausea, vomiting, light-headedness
• syncope in 9% of patients often due to extension of dissection into pericardium producing pericardial tamponade; can aldo be due to brief cessation of cerebral blood flow

Workup

• contrast CT aortography = test of choice (100% sensitive, 98% specific) 
• faster and more readily available than TEE or MRI 
• CXR is abnormal in 80-90% of patients, however is nonspecific and rarely diagnostic 
• mediastinal widening occurs in majority of cases
• routine labs rarely helpful
• ECG useful for excluding MI 
• bedside cardiac ultrasound useful for identifying pericardial effusion, tamponade, or aortic regurgitation

Management

There are 2 goals of medical management: 

     1) reduce blood pressure (target SBP 100-120 and HR <60)

     2) decrease the rate of rise of arterial pulse (dP/dt) to reduce shearing forces

First-line agent: beta-blockers (esmolol, labetalol)

• both are short-acting and titratable 
• both can be used as monotherapy 
• esmolol: 500 ug/kg IV bolus followed by 50-200 ug/kg/min maintenance drip 
• labetalol: 20mg IV q5-10 min, can increase up to 80mg IV doses until HR <60
• do not exceed 300mg 
• 1-2 mg/min maintenance drip 

Non-beta-Blocker agents such as nitroprusside or nifedipine can be considered but only after a beta-blocker is on board to prevent reflexive tachycardia which will increase shearing forces.

Opioids are a good choice for analgesia (fentanyl, morphine) as they will also decrease sympathetic tone and help reduce blood pressure and shearing force. 

Patients on anti-platelet drugs (aspirin, plavix, etc), many require platelet transfusion in anticipation of surgery. The patient in this case received 1 unit of platelets given he reported taking aspirin just prior to presentation.

Disposition

• All type A dissections require prompt surgical management
• Type B dissections can usually be managed with conservative medical therapy alone, disposition is dependent on the clinical situation (history and exam) 

Outcome

  

References: 

Rosen's Emergency Medicine Concepts and Clinic Practice, 8th Ed, 2014, Chapter 85: Aortic Dissection by Felix K. Ankel 

Questions, comments, feedback? Please leave a comment below!

Rude Awakening

A 53 year-old male with history of asthma, methamphetamine and cocaine use, and ventral hernia, presents with chief complaint of sudden onset chest pain that occurred this morning. Patient endorses a severe constant sharp pain with associated shortness of breath and nausea that woke him from sleep. He took an aspirin just prior to arrival with no relief. On exam the patient is diaphoretic. Recent blood work obtained for upcoming hernia repair shows normal renal function.

A CXR and CTA chest are obtained and show the following: 

Can you guess the diagnosis? 

Leave a comment below and tell us how you would manage this patient. 

The actual diagnosis for this real-life case will be posted in 1 week.