S3594 The Way to a Man’s Heart Is Through His Stomach

Abstract

INTRODUCTION: ‘Pneumoperitoneum’ is the accumulation of free gas in the peritoneal cavity. Common causes include ventilator-induced barotrauma, bowel perforation, endoscopic procedures and abdominal surgeries. Tension pneumoperitoneum (TPP) is the acute excessive accumulation of free gas resulting in venocompression and cardiovascular compromise. We present an unusual case of TPP that could have led to cardiac arrest. CASE DESCRIPTION/METHODS: 64-year-old man with history of alcohol abuse and abdominal pain for 2 days was brought to ER after he was found collapsed at home with last known normal 20 minutes prior. CPR was initiated and EMS was called. EMS noted empty beer cans near the patient. He was resuscitated per ACLS protocol and ROSC was achieved. On ER examination, patient was unresponsive, in shock and with a tensely distended abdomen. Labs showed AST 435 units/L, ALT 236 units/L, lactic acid 13.4 mMol/L, alcohol level 19 mg/dL and ammonia 155 mcg/dL. CXR demonstrated air under diaphragm bilaterally (Figure 1). CT showed large pneumoperitoneum, free fluid and compressed IVC (Figures 2a and 2b). He underwent emergent laparoscopy. Intra-abdominal pressure was 28 mmHg using an indwelling foley catheter with an initial release of gas during laparoscopy. He was found to have a large 1.5 cm perforated gastric ulcer which was repaired. Patient had multiorgan dysfunction but was stabilized in ICU. However, he did not awaken and was declared brain dead 3 days after admission to hospital. DISCUSSION: We hypothesize that our patient had TPP causing severe abdominal compartment syndrome leading to cardiovascular collapse and cardiac arrest. The rapid deterioration culminating in arrest suggests a mechanical component to the arrest rather than a pure hypovolemic and inflammatory state. Radiologic findings of a large pneumoperitoneum compressing the abdominal viscera as well as the IVC have previously been described with TPP. Smet et al described a case like ours of spontaneous TPP presenting with cardiac arrest. In such cases emergent needle decompression can be lifesaving.Figure 1.: demonstrating CXR finding of air under diaphragm bilaterally (Yellow arrows).Figure 2a.: (Axial view) demonstrate CT scan findings of a large pneumoperitoneum (yellow arrows) compressing the abdominal viscera and IVC into a central mass (blue arrows) with free fluid in the peritoneal cavity (red arrows).Figure 2b.: (Sagittal view) demonstrate CT scan findings of a large pneumoperitoneum (yellow arrows) compressing the abdominal viscera and IVC into a central mass (blue arrows) with free fluid in the peritoneal cavity (red arrows).