Erect Chest X-ray Research Articles

Occult pneumothorax in patients with blunt chest trauma: key findings on supine chest radiography.

In patients with multiple trauma, a supine chest radiography [chest X-ray (CXR)] is preferred over a erect CXR. However, this method has limitations in detecting post-traumatic pneumothorax. The use of chest computed tomography (CT) to detect traumatic pneumothorax is well known. However, pneumothorax that is not detected before a chest CT scan is known as an occult pneumothorax (OP), and it can cause serious complications in the patient. This study sought to evaluate the frequency and risk factors for OP in trauma patients. Patients who suffered thoracic trauma at the Level 1 Regional Trauma Center of Wonju Severance Christian Hospital between 2015 and 2022 were included in this study. All patients were at least 18 years old. The study reviewed all patients' supine CXR and chest CT images and classified them into five radiographic diagnoses: pneumothorax, rib fracture, subcutaneous emphysema, lung contusion, and pneumomediastinum. The study included 1,284 patients, all with diagnoses of pneumothorax, rib fracture, subcutaneous emphysema, lung contusion, and pneumomediastinum following supine CXR and chest CT. The patient's average age was 58.3±15.2 years. Pneumothorax diagnosis on supine CXR had the lowest accuracy, at 46.7%, and the lowest sensitivity, at 12.7%. In univariate analysis, rib fracture, lung contusion, and subcutaneous emphysema on supine CXR were all found to be statistically significant regarding traumatic OP. In multivariate analysis, the risk factors for OP were lung contusion [odds ratio (OR), 1.440; 95% confidence interval (CI): 1.115-1.860; P=0.005] and subcutaneous emphysema (OR, 25.883; 95% CI: 13.155-50.928; P<0.001) on supine CXR. The lung contusion and subcutaneous emphysema in supine CXR of trauma patients indicate the presence of OP. Therefore, if chest CT cannot be performed immediately due to unstable vital signs or other circumstances, recognizing the above radiological findings of traumatic pneumothorax may be necessary.

O052 Erect chest X-ray is inadequately diagnostic and falsely reassuring in assessment of abdominal visceral perforation: a retrospective cohort study

Abstract Introduction Pneumoperitoneum refers to air in the abdominal cavity due to abdominal visceral perforation and can be visualised as air under the diaphragm on erect chest x-ray. This study aims to evaluate the accuracy of erect CXR in detecting the presence of abdominal visceral perforation. Methods A retrospective cohort study in a single centre was conducted between January 2014 and January 2020. The study population comprised of all patients with gastrointestinal perforation confirmed by assessment during emergency laparotomy. The outcome measure of this study was perforation detection rate, defined as detection of air under diaphragm in preoperative erect CXR confirmed by two independent qualified radiologists. Results A total of 219 patients were eligible for inclusion in this study. Among 219 patients with intraoperative evidence of abdominal visceral perforation, preoperative erect CXR showed air under diaphragm in 43 patients. The perforation detection rate was 20% (95% CI 15-26%). Subgroup analysis based on the level of perforation showed that the perforation detection rate was 32% (95% CI 21-43%) in patients with upper gastrointestinal perforation and 13% (95% CI 8-20%) in patients with lower gastrointestinal perforation. Conclusion Erect CXR can only detect the presence of abdominal visceral perforation in 20% of patients and does not provide any information about the level or cause of perforation. The time is to move away from the use of erect CXR in assessment of patients with acute abdominal pain. It is inadequately diagnostic and falsely reassuring. All patients with suspected perforation should have immediate CT scan.

Prognostic value of free air under diaphragm on chest radiographs in correlation with peritoneal soiling intraoperatively

Gastrointestinal perforation is a significant injury that originates mainly from gastrointestinal ulcers. It is associated with a high rate of morbidity and mortality. The height of the column of the air under the diaphragm can be used to estimate the amount of peritoneal soiling due to viscus perforation. This study aimed to determine the correlation between this estimate and the incidence of morbidity and mortality. To achieve this aim, a prospective cohort study was conducted on 83 patients at Kasr al ainy hospital who, between March 2021 and March 2022, presented to the emergency department with free air under the diaphragm at chest X-ray and required surgical intervention for a perforated viscus. For each case, the amount of peritoneal soiling and the amount of air under the diaphragm as determined by a chest X-ray were recorded. The mean air under the diaphragm in a plain erect chest X-ray was 1.78 ± 1.92cm, and the mean amount of peritoneal soiling was 1201.83 ± 948.99 CC. There are positive correlations between the amount of air under the diaphragm as shown on an X-ray and the size of the perforation (p = 0.034), the amount of peritoneal soiling (p = 0.003), and the mortality (p = 0.013). There was a statistically significant correlation between air under the diaphragm according to X-ray and the amount of peritoneal soiling in patients with a perforated viscus. This measure can be used as a sensitive tool to predict morbidity and mortality as more free air in the chest X-ray is associated with significant mortality. These results may enhance the decision making using sensitive and available tool of diagnosis.

Delayed asymptomatic blunt traumatic diaphragmatic hernia: an unusual case report

IntroductionTraumatic diaphragmatic hernia (TDH) is uncommon, being encountered in around 0.8%-8% of patients with blunt abdominal trauma. Severe comorbidities such as fractures and thoraco-abdominal or head injuries that accompany TDH, are responsible for poor prognosis and often mask diaphragmatic injury itself. Objective of this case report was to highlight rare blunt TDH case to avoid missed diagnosis leading to complications. Case descriptionSixty seven-year old man presenting with right chest pain without difficulty of breathing after falling from stairs 1 hour before hospital admission. On clinical examination, vitals were stable, but with decreased breath sounds on right lower side of chest. Patient had history of trauma from being crushed by elevator 40 years ago without any proven diaphragmatic injury. Initial erect chest X-ray findings were inhomogeneous opacity shadow on lower right hemithorax suspected to be diaphragmatic hernia and 7th right rib fracture with pleural effusion. Thorax CT scan showed herniated right lobe of liver, gall bladder, and mesenteric fat on right hemithorax causing displacement of mediastinal structures. Patient was diagnosed with delayed TDH and hemothorax caused by newly fractured rib. Patient was referred to a better-equipped facility due to the limited surgical facilities in referring hospital. ConclusionDelayed TDHs are not common, but can lead to serious consequences. Blunt TDH occurs more often on left than on right side, in ratio of approximately 3:1. Traumatic diaphragmatic hernia is sometimes diagnosed many years after traumatic event due to latent phase of disease possibly ranging from days to years.

Colosplenic fistula presentation in the context of undiagnosed colon cancer: Case report and review of literature.

Introduction and importanceEnteric fistulas commonly arise from inflammatory, infectious, or neoplastic processes. Colosplenic fistulas are rare with only several reported worldwide.Case presentationHerein, we present a case of colosplenic fistula in a 39-year-old gentleman with past history of rectal cancer previously in remission. He was admitted with severe abdominal pain and hemodynamic instability due to septic shock. The erect chest x-ray revealed pneumoperitoneum under the diaphragm.Clinical discussionLaparotomy was performed and ileum perforation was managed by resection and anastomosis. The post-op recovery was complicated by a febrile episode. To locate the source of infection a contrasted abdominal computed tomography was ordered, confirming the presence of a splenic abscess, suggestive of colosplenic fistula. We proceeded with laparotomy for drainage of the abscess, with splenectomy and splenic flexure resections. He was discharged 40 days post-op at a pre-morbid state.ConclusionDue to the high prevalence of colon cancer worldwide, novel complications such as the one reported here, are important to be reflected on. We hope this case can exemplify the significance of higher index of suspicion in at risk patient groups by the surgical teams and appropriate training on acute management of this rare complication.

Effects of sex, age, size and location of perforation on the sensitivity of erect chest X-ray for gastroduodenal perforation

IntroductionThis study aimed to evaluate the sensitivity of the erect chest X-ray for diagnosing subdiaphragmatic free air. Furthermore, we examined the effects of different parameters, including sex, age, size of perforation, and the location of perforation on the sensitivity of the erect CXR. MethodsThis study included all patients with perforated peptic ulcer (107 cases) referred to the Shahid Rajaei hospital of Tonekabon from April 2015 to August 2020. The perforated peptic ulcer was confirmed by laparotomy, and the erect chest X-ray was performed as a preoperative procedure. The collected checklist was analyzed using the IBM SPSS Statistics V22.0 software. ResultsAchieved results showed total sensitivity of 86% for the erect chest X-ray. The sensitivity of the erect CXR was calculated, 88.5% and 82.6% at males and females, respectively. However, the sensitivity for different age groups was about 86%. The larger perforations resulted in higher sensitivity. Furthermore, the erect chest X-ray sensitivity for duodenal perforations (92.5%) was significantly greater than the gastric perforations (75%). ConclusionBased on this study, the erect chest X-ray could be utilized as a preoperative procedure with total sensitivity of 86% for gastroduodenal perforations. Patients' age and sex have no significant impact on the sensitivity (P-value > 0.05). However, the size and location of perforation significantly influenced the sensitivity (P-value < 0.05). The results demonstrated that larger perforations and duodenal perforations lead to the higher erect CXR sensitivity. Implications for practiceThe erect chest X-ray is used as a routine procedure to detect subdiaphragmatic free air in gastroduodenal perforations. The effects of different factors such as age, sex, size of perforation, and the location of perforation on the sensitivity of the erect chest X-ray are discussed for the first time in this study.

Generalized Secondary Peritonitis in a Teaching Hospital: a Clinical Profile

Inflammation of the peritoneum and peritoneal cavity, usually caused by a localized or generalized infection, is called peritonitis. The common causes of secondary peritonitis are peptic ulcer perforation, acute appendicitis, colonic diverticulitis, and PID. The present study aimed to determine the etiology, clinical presentation, and treatment outcome and identify the factors responsible for the poor outcome in the patients with generalized secondary peritonitis at Department of Surgery, Dr. RPGMC Kangra at Tanda, HP, India. The study enrolled 153 patients admitted to the surgery department with a diagnosis of acute generalized secondary peritonitis within a period of 1 year from December 2016 to November 2017. After admission, detailed history was recorded. The data regarding possible etiology, duration of symptoms, clinical presentation, diagnostic procedures, surgery performed, comorbidities, postoperative morbidity, and mortality was recorded. The age of patients ranged from 12 years to 90 years with a mean age of 42.75 years. Male/female ratio in our study was 6.29:1. Pain abdomen, fever, abdominal distension, abdominal guarding, and rigidity were the major signs and symptoms in our study. Of the patients, 65.36% presented after 24 h of onset of symptoms. Of the patients, 13.76% were having comorbidities, where respiratory disease was the most common one. Pneumoperitoneum on erect chest X-ray was found in 88.23% of the patients. Peptic ulcer disease was the commonest etiology of secondary peritonitis followed by enteric fever-associated perforation. Exploratory laparotomy and omental patch closure (Cellan jones and Modified Graham) were the most common surgery done. Postoperative morbidity was seen in 20.9% of our patients. We observed that the complication rate was higher in patients with enteric perforation (33.3%), followed by peptic ulcer disease, in 19.5% cases. To conclude, secondary peritonitis in India continues to have different spectrum as compared with Western countries with peptic ulcer disease as the most common etiology. Omental patch repair may be the preferred procedure for peptic ulcer perforation as it is technically easy and has better results. A prompt diagnosis, aggressive resuscitation, and timely surgical intervention are life-saving for all patients with generalized secondary peritonitis.

Situs Inversus Totalis with Left-Sided Appendicitis: A Case Report

Introduction: Left-sided acute appendicitis (LSAA) develops in association with two types of congenital anomalies: situs inversus totalis (SIT) and midgut malrotation (MM). A Left sided appendicitis is an ambiguous and difficult diagnosis to make. Aim: To present a proven case of left-sided acute appendicitis (LSAA) associated with situs inversus totalis (SIT). Case Report: A case of Left appendicitis was evaluated in a 28-year-old Asian male, who presented to our hospital in Feb. 2016, with lower abdominal pain more on left side and suspected diverticulitis or acute appendicitis with unusual appendix location. The patient doesn’t recall any history of abdominal surgery or about situs inversus totalis, abdominal and pelvic ultrasound was done, left iliac fossa appendicitis was diagnosed, Erect chest X-ray including upper abdomen revealed dextrocardia and stomach air on right side (situs inversus totalis), the patient underwent diagnostic Laproscop and Endoscopic resection of the appendix, with no incidents, and then discharged without complications, follow visits went unremarkable. Conclusion: The diagnosis of left lower quadrant pain is based on well-established clinical symptoms, physical examination and physician’s experience.

Perforated isolated jejunal diverticulum: a rare cause of acute abdomen

A 45-year-old female presented with pain in peri-umbilical region for past one day along with history of non-bilious vomiting and non passage of stool and flatus for past one day. On physical examination, patient was afebrile, mild dehydration was present, tachycardia of 102 beats per minute with normal blood pressure. On clinical examination, the abdomen was diffusely tender with rebound tenderness. Bowel sounds were absent. Laboratory investigations revealed leucocytosis. An erect plain chest X-ray was done, didn’t reveal any gas under the diaphragm. Contrast enhanced computed tomography abdomen was done which showed a hollow viscus perforation with intra-abdominal free air and pelvic free fluid. Patient was resuscitated with IV fluid, broad-spectrum antibiotics were started and immediately taken up for exploratory laparotomy. Three jejunal diverticula identified at mesenteric border, with pin-head perforation in one of the diverticula. Small bowel resection including the three diverticula and primary end-to-end anastomosis was performed. Post-operative period was uneventful. Patient discharged on satisfactory conditions. This case stresses the importance to consider this entity in cases of unexplained gastrointestinal symptoms because any treatment delay may lead to unsuccessful clinical outcome.

Chronic Mesentero-Axial Gastric Volvulus Associated with a Parahiatal Diaphragmatic Hernia: A Rare Entity

Gastric volvulus, a rare entity, seldom presents with diaphragmatic hernia and is usually missed during preliminary workup (Demmy et al. in Ann Thorac Surg [Internet] 58(1):226–227, 2010). We present the case of a 55-year-old lady who presented with vomiting, pain upper abdomen, heartburns, and episodic unproductive retching for the past 6 months. The diagnosis of diaphragmatic hernia was made on erect chest X-ray and the barium study findings. Intraoperatively, a mesentero-axial gastric volvulus was found to be associated with a parahiatal hernia (Scheidler et al. in Ann Thorac Surg 73(2):416–419, 2002). The contents were reduced back into the abdomen, and diaphragmatic defect was approximated. Chronic gastric volvulus with or without diaphragmatic hernia should be kept as a differential in old age groups suffering from intractable dyspepsia unresponsive to conventional therapies (McElreath et al. in Dig Dis Sci 53(11):3033–3036, 2008; Teague et al. in Br J Surg 87(3):358–361, 2000).

Duodenal ulcer perforation in a 3-year-old child with lower respiratory tract infection and hyperthyroidism

Peptic ulcer disease (PUD) in children remains rare and difficult to diagnose before the onset of complications. We describe a 3-year-old child with perforated duodenal ulcer, associated with lower respiratory tract infection and hyperthyroidism. Upper GI endoscopy revealed three clean based ulcers in the first part of duodenum, erect chest x-ray showed bilateral gas under diaphragm and CT scan confirmed massive pneumoperitoneum. Emergency exploratory laparotomy detected perforation in the anterior wall of duodenum, managed with simple sutural closure. PUD in children is rare and high index of suspicion is required to prevent complications.

A rare case of spontaneous common bile duct perforation

Spontaneous perforation of the common bile duct (CBD) in adults is an extremely rare complication of gallstones. It is challenging to establish the diagnosis pre-operatively however with increasing utility of computer tomography, there may be subtle features visualized. We describe a case of a 35 year old Indian male who presented with an acute abdomen and was found to have biliary peritonitis secondary to a spontaneous CBD perforation. Mr JJ presented with sudden onset of abdominal pain associated with vomiting and diarrhea. He had generalized abdominal peritonitis. Initial erect chest x-ray was unremarkable for free air under the diaphragm, hence a CT was performed which revealed moderate amounts of free fluid around the 2nd part of the duodenum extending along the anterior para-renal space into the pelvis, with a 4mm distal CBD stone resulting in mild upstream dilatation. The gallbladder was decompressed and the CBD wall was not well visualized in the mid-portion, raising the possibility of perforation. An exploratory laparotomy revealed generalized biliary peritonitis secondary to a 2 cm CBD perforation just distal to the cystic duct junction. Choledochoscopy confirmed the small 4mm distal CBD stone which was advanced successfully through the ampulla into the duodenum. He underwent abdominal lavage, cholecystectomy, choledochectomy and a roux-en-Y hepatico-jejunostomy reconstruction. His recovery was uneventful. Histology confirmed focal transmural necrosis of the bile duct with fibrosis and micro-abscess formation. Clinicians should be aware that whilst spontaneous extrahepatic bile duct perforations are rare, it is important as timely diagnosis can be life-saving.

An unusual case of spontaneous pneumomediastinum: Case report

Introduction Spontaneous pneumomediastinum (SPM) is rare, with an incidence of 1/25,000. It is defined as extra luminal free air within the mediastinum, not associated with trauma. A classic clinical triad consists of pleuritic chest pain, dyspnoea and subcutaneous emphysema. SPM is self-limiting and symptoms can be managed conservatively. However despite a good prognosis, secondary causes should be excluded. Case description Miss AG, 27 year old with a known history of Ulcerative Colitis being treated with azathioprine and adalimumab, presented to the ED with a two week history of progressively worsening shortness of breath and left sided pleuritic chest pain. She reported a 3 day h/o ongoing fever, rigors for which she was being treated with Amoxicillin 500mg tds. The patient had no previous history of respiratory conditions and was a non-smoker. The patient saturated at 96% on 2L of Oxygen with a respiratory rate of 19. She was apyrexial, normotensive and acyanotic. Clinical findings on auscultation revealed left sided bronchial breathing, an erect postero-anterior chest x-ray revealed dense opacification throughout the left mid and lower zone. As she was increasingly symptomatic, she went onto have a CTPA, which showed a pneumomediastinum. A discussion with the thoracic surgeons followed and an urgent CT thorax and abdomen with oral gastrografin was carried out to exclude oesophageal perforation. This scan did not reveal any extravasation of contrast around the oesophagus to suggest a perforation or a leak. The patient improved clinically, discharged in 6 days, she was kept nil by mouth for 48 hours once the CT had confirmed that there was no perforation. Results and Conclusions SPM usually has a benign and favourable clinical course and is usually self-limiting. It is more commonly seen in young men. The pathophysiological process behind SPM was initially described by Macklin in 1944, who described a rupture of the terminal alveoli, secondary to pressure differences across the alveolar membrane causing air to leak into the lung interstitium and consequently into them mediastinum. In a retrospective study by Park et al., 44% of the patients had a precipitating factor, with the most common being cough. Literature suggests that the most common symptoms reported in cases are usually chest pain, which is usually pleuritic in nature and dyspnoea Subcutaneous emphysema is also reported as common clinical sign and has a frequency ranging from 40% to 100% in cases. Moreover, the characteristic sign of systolic crackles on auscultation known as Hamman’s sign can also be heard in 30% of cases. Diagnosis in this case was made based on the CTPA though it is more commonly based on chest x-ray findings. Postero-anterior view establishes the diagnosis in about two-thirds of patients with the three commonest findings: air streaks in the superior mediastinum, prominent left sided silhouette of the heart and subcutaneous emphysema of the neck and shoulder. For this reason, a chest CT scan is a more conclusive and sensitive scan, which is considered the gold standard investigation for SPM. More importantly, a CT scan with an oral contrast, as in this case, will allow us to distinguish between secondary causes of a SPM such as an oesophageal leak or rupture. The prognosis is good and treatment is mainly conservative for those diagnosed. The average clinical course, reported in the retrospective study by Takada et al. was 1.8 days after diagnosis, with an average of 7.8 day of hospitalization. Complications such as hypertensive pneumomediastinum, pneumopericardium, and mediastinitis can occur and patients should be monitored throughout their admission. Take home message In conclusion, spontaneous pneumomediastinum is a rare condition, and is known to have a favourable clinical course, with symptoms of pleuritic chest pain and dyspnoea improving within a few days. Chest CT is the gold standard radiological investigation to confirm diagnosis whereby measures must be taken to exclude secondary causes of SPM. Patients can be treated conservatively and must be monitored for life threatening complications.

A Woman with Abdominal Pain, Vomiting and ‟Air Under Diaphragm".

A 49-year-old female presented to the emergency department with acute onset of diffuse abdominal pain and vomiting of one day duration. Her vitals were stable and her abdomen showed diffuse tenderness. She was subjected to erect chest X-ray with both domes of the diaphragm [Figure 1], which showed air under the diaphragm. Open in a separate window Figure 1 Postero-anterior view of chest X-ray showing air under the diaphragm (red arrows).

A case of progressive orthopnoea and shoulder pain secondary to bilateral diaphragmatic paralysis

A 45-year-old man with a raised body mass index presented with an acute history of right lower chest pain and increasing breathlessness. C reactive protein, D dimer and cardiac echocardiography...

Laparoscopic versus open operation for perforated peptic ulcer in pediatric patients: A 10-year experience

BackgroundPerforated peptic ulcer (PPU) is a relatively uncommon condition in children. We aim to evaluate and compare the outcomes of laparoscopic omental patch repair versus open repair for PPU in pediatric patients. MethodsChildren who underwent omental patch repair for PPU from 2004 to 2014 in our hospital were reviewed retrospectively. Patient demographics, perioperative as well as intraoperative details and surgical outcomes, were analyzed. ResultsThirteen patients were identified, and all presented with abdominal pain. The median age of the study group was 14.9years (range 6.3 to 18.4years). Radiological evidence of pneumoperitoneum on erect chest x-ray (CXR) was found only in five patients (38.5%). None of the patients had a known history of peptic ulcer disease. Diagnosis other than PPU was made in five patients preoperatively. Laparoscopic repair was attempted in eight patients with one of them requiring conversion. There was no significant difference in patient demographics when compared with the open repair group. The perforation site was in the duodenum in 11 patients and in the antrum in two patients. The mean size of perforation was larger in the open repair group (p=0.005). Although the operating time was longer in the laparoscopic group (p=0.51), the length of hospital stay was significantly shorter (p=0.048). Only two patient diseases were Helicobacter pylori related. ConclusionClinical features of perforated peptic ulcer in children are different from adults. Risk factors are less frequently identified. Laparoscopic omental patch repair is a feasible surgical option and is associated with satisfactory outcomes in pediatric practice.

The thymic flap for bronchial stump reinforcement following lobectomy

Results A sixty-one year old male presented with a one-day history of severe left chest pain and a five-week history of a nonproductive cough. He had a history of multiple bilateral rib fractures following a motor vehicle accident. He was an exsmoker with no previous asbestos exposure. His respiratory rate was 22/minute with room air oxygen saturation of 95%. He had absent left basal breath sounds. Blood tests were normal. An erect chest x-ray revealed a left sided pleural effusion and a 2.6cm right upper lobe mass, confirmed with CT imaging..Although bronchoscopy and thoracocentesis were negative for malignancy, transbronchial endoscopic ultrasound needle aspiration of station 4R lymph nodes reported non-small cell lung carcinoma (T1B,M0,N2). He responded to neoadjunctive chemoradiotherapy. Follow-up PET/CT imaging showed a reduction in the apical mass to 2.2cm. Right upper lobectomy was performed via a 5th ribspace posterolateral thoracotomy where a solitary malignant intrapulmonary peribronchial lymph was identified. Due to extensive pleural adhesions from previous rib fractures, the right inferior tip of the thymus was mobilized from the pericardium and retrosternal attachments and used to secure the bronchial stump. The patient remains well following an uneventful recovery. Post-lobectomy bronchopleural fistula remains a rare and serious complication with an incidence rate between 0.5%-0.99% [2]. Persistent empyemas necessitating open drainage and prolonged hospitalization contribute to a high mortality rate ranging from 25%67% [2]. A reduction in complications had been reported with the incorporation of pleural,diaphragmatic, intercostal and azygous vein bronchial stump reinforcements [1]. In our case, the thymic flap was mobilized due to inability to successfully dissect the parietal pleura. Infante et al (2004) evaluated the protection of right pneumonectomy bronchial sutures with a pedicled thymus flap where 82% (27/33) of cases had a satisfactory thymic inferior pole length [3].

Right Upper Quadrant Pain in a 21-Year-Old Man

Question: A 21-year-old man with attention deficit hyperactivity disorder developed acute-onset, severe, right upper quadrant pain shortly after being taken into police custody. He volunteered no further past medical history or gastrointestinal symptoms other than pain. On examination, vital signs were: Heart rate, 68; blood pressure, 110/74 mmHg; temperature 37.5°C; respiratory rate, 14; and SpO2, 97% on room air. There was generalized guarding with marked rebound tenderness maximally in the right upper quadrant; electrocardiograph showed normal sinus rhythm and erect chest x-ray did not demonstrate a pneumoperitoneum. Bloods included: Hemoglobin, 16.3 g/dL; white cell count, 6.8 × 109/L; urea, 2.8 mmol/L; creatinine, 71 μmol/L; bilirubin, 17 μg/L; alkaline phosphatase, 65 U/L; alanine transferase, 10 U/L; and C-reactive protein, 48 mg/L; all other blood results were unremarkable. A provisional diagnosis of an acute appendicitis was made and he was taken to the operating room without further imaging, where the following was found (Figure A, B). What is the diagnosis? See the Gastroenterology web site () for more information on submitting your favorite image to Clinical Challenges and Images in GI. On laparoscopy, a classical mid-gut malrotation was found with a centrally positioned caecum. In addition, a large Meckel's diverticulum was seen arising from the ileum behind Ladd's bands in the right upper quadrant (Figure A). On open conversion, Ladd's bands were divided and the gut mobilized to the anatomical position. Given the broad-based diverticulum, small bowel resection with end-to-end anastomosis was performed, together with cecopexy and appendectomy. Histologic examination revealed Meckel's diverticulitis with areas of ectopic duodenal mucosa (Figure B) and minor regenerative changes throughout adjacent small bowel. Later, on gaining a collateral history, it transpired that he had a lifelong record of hospital admissions for abdominal complaints for which no cause had been identified. Intestinal malrotation is a congenital anomaly affecting 1 in 500 births1Torres A.M. Ziegler M.M. Malrotation of the intestine.World J Surg. 1993; 17: 326-331Crossref PubMed Scopus (191) Google Scholar and arises as a deviation from the normal 270° counterclockwise rotation of the gut during embryogenesis. Overall, 80% present in the neonatal period,2Von Flue M. Herzog U. Ackermann C. et al.Acute and chronic presentation of intestinal nonrotation in adults.Dis Colon Rectum. 1994; 37: 192-198Crossref PubMed Scopus (108) Google Scholar although some remain undetected until adulthood when they may develop obstruction owing to volvulus or internal herniation. Others are found incidentally or after imaging for intermittent abdominal pain, which may represent episodes of spontaneously resolving subacute obstruction. In this case, because the bowel appeared grossly normal, symptoms were attributed to the Meckel's diverticulum. These 2 mid-gut abnormalities are not classically associated and indeed it is difficult to determine whether the malrotation was an incidental finding in this case. If so, the inflamed diverticulum may have been a serendipitous occurrence given that surgical correction of malrotation is the only prophylaxis against future catastrophic complications. This case demonstrates that serious underlying pathology cannot be reliably ruled out by routine admission investigations, highlighting the importance of clinical intuition in the absence of objective evidence. Furthermore, of the reported cases of intestinal malrotation presenting acutely in adult life, many are associated with a long history of nonspecific pain, emphasizing the need for thorough investigation of chronic pain beginning in childhood, regardless of distracting behavioral or psychiatric issues.

Emphysematous pyelonephritis: a rare but potentially life-threatening complication of poorly controlled diabetes

A 50-year-old man with poorly controlled type 1 diabetes presented with a 48-h history of diarrhoea, vomiting and poor appetite. He had recently visited India where he was treated for enteric fever. On admission he was febrile, dehydrated, hypotensive and tachycardic with diffuse abdominal tenderness. Plasma glucose was 56.1 mmol/L, venous pH 7.11, and urinalysis showed significant ketonuria, confirming diabetic ketoacidosis. He was treated with intravenous fixed dose insulin and fluids. In view of his symptoms, an erect chest and abdominal X-ray were performed to exclude small bowel obstruction and perforation respectively. The abdominal X-ray showed a gas density adopting the outline of the right kidney. Computed tomography of the abdomen showed gas within the parenchyma of the right kidney, in keeping with emphysematous pyelonephritis, and also a right sided hydronephrosis and hydroureter. Blood cultures were positive for Enterobacter aerogenes. He was reviewed by the urologists and infectious diseases team, was started on intravenous meropenem and had a percutaneous nephrostomy, drainage of gas from the emphysematous region of the right kidney and ureteric stent insertion. He responded well to treatment and was discharged on a basal bolus insulin regime, with his nephrostomy and drain being removed before discharge. He is under out-patient review by the diabetes, urology and infectious diseases teams. Emphysematous pyelonephritis is a potentially life-threatening complication of poorly controlled diabetes, characterised by bacterial production of gas within the kidney parenchyma. Early diagnosis and multidisciplinary care can lead to good outcomes, avoiding the need for emergency nephrectomy.

Diagnostic and therapeutic challenges of isolated small bowel perforations after blunt abdominal injury in low income settings: Analysis of twenty three new cases

BackgroundIsolated small bowel injury (ISBI) related to abdominal blunt trauma is rare. Timely diagnosis could be difficult, especially in the absence of modern imaging and laparoscopic facilities. The determinants of mortality under such circumstances are unclear. MethodsThis study presents twenty three cases of ISBI related to blunt abdominal injury identified between January 2005 and December 2009 in a level III Hospital in Limbe, Cameroon. Data were retrieved from an ongoing prospective study on injuries and augmented by analysis of individual patient's files. We analysed information regarding modalities of diagnosis, delay between injury and diagnosis, operative findings, treatment and outcome. ResultsThe ages of our patients ranged from 7 to 38 years with a mean of 19 years. Thirteen patients were children below the age of 16. The most frequent mechanism of injury was a fall (n=11). Associated lesions were identified in 7 patients. Delay between injury and diagnosis was above 12h in 16 patients. Fifteen cases were admitted with obvious signs of peritonitis. Erect chest X-ray identified a pneumoperitoneum in 11 of the 17 patients for whom it was requested. Most perforations were located in the ileum. A total of 7 complications occurred in 5 patients. These included 4 cases of post-operative peritonitis. Two patients with at least one associated lesion died. ConclusionISBI is seldom suspected. This causes delay in diagnosis and most cases present with a diffuse peritonitis. Early diagnosis and management in low income environment is likely to be improved by a greater awareness of clinicians about this injury, serial clinical assessment and repeated erect chest X-ray, rather than sophisticated tools such as CT scan or laparoscopy.