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  • Can't wait for Dr. Ragland to start posting!

    We want clinical puzzles!

  • #2
    Here is a puzzle for you 3b: 69 years old female, enters the ED with the history of sudden onset of abdominal pain, nausea and one episode of vomiting. Pain in the epigastrium penetrating through to the back. ROS unremarkable otherwise. No significant past history. Exam shows tenderness in the epigastric and RUQ, no rebound. Bowel sounds are present. WBC:18.3K 6% bands. Flat and upright x-rays of the abdomen show no Free air. Non specific gas pattern of the small and large bowel. Well there is a bit more info I can give you on the plain films, but first let us see if we may start with a DD.

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    • #3
      I hate DDx's so I'll guess the plain films showed calcification of the aorta and she had a leaking AAA. Or it showed a gallstone and she had cholecystitis (that's too easy an answer but I did not want to overlook the potentially obvious)

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      • #4
        You are right not so fast and not easy The palin film showed, what appeared to be a few bubbles in the retroperitoneum, in the region of the head of the pancreas. So what next?

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        • #5
          ?Perforated DU

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          • #6
            Ct abdo stat with IV contrast?

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            • #7
              DDX =
              1) what's likely
              2) What's treatable
              3) What's deadly

              Certainly sounds GI, but pain to back also assoc with vascular catatrophes such as dissection & AAA. Single episode of vomiting reduces likelihood of Mallory-Weiss but increases likelihood or Borhaave's. If vitals are stable, I would agree with CT IV contrast - if vitals unstable then patient needs bright lights and cold steel (trip to OR) ASAP. No PO contrast which could complicate and contaminate ruptured hollow viscus.

              ECG results? Unlikely clinically to be cardiac dz, but patient will likely go to OR and ECG essential in 69 year old female to properly assess ASA risk.

              PS - bubbles around pancreas suggest retroperitoneal perf.
              Last edited by robodoc911; 04-12-2004, 11:06 PM.
              Ragster

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              • #8
                Good show Ragster. Patient was stable. went for a CT with gastrograffin and this showed pooling of contrast behind the head of the pancreas at about the level of junction between 2nd and 3rd part of duodenum. As all of you know there is no peptic ulcer disease in this location. No nistory of trauma. Hence the diagnosis of perforated diverticulitis of the duodenum was made. Took the Patient to the O.R a few hours later.

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                • #9
                  CT scanning is getting better, but still has a significant miss rate for perforated hollow viscus.[1-5] ACEP has made a Level B recommendation in blunt abdominal trauma that is probably relevant to the detection of non-traumatic perforation of a hollow viscus also: "...CT alone cannot be used to exclude either bowel, diaphragm, or pancreas injury...."[1]

                  ---------------------------------------------------------------------

                  References:

                  [1]Clinical policy: Critical issues in the evaluation of adult patients presenting to the emergency department with acute blunt abdominal trauma. Ann Emerg Med; 2004 Feb; 43(2); 278

                  [2] Fakhry SM, Watts DD, Luchette FA. Current diagnostic approaches lack sensitivity in the diagnosis of perforated blunt small bowel injury: analysis of 275,557 trauma admissions from the EAST multi-institutional HVI trial. J Trauma 2003;54:295-306.

                  [3] Todd SR. Critical concepts in abdominal injury. Crit Care Clin; 01-JAN-2004; 20(1): 119-34.

                  [4] Ceraldi CM, Waxman K. Computerized tomography as an indicator of isolated mesenteric injury: a comparison with peritoneal lavage. Am Surg 1990;56(12):806-10.

                  [5] Nolan BW, Gabram SG, Schwartz RJ, Jacobs LM. Mesenteric injury from blunt abdominal trauma. Am Surg 1995;61(6):501-6.
                  Ragster

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                  • #10
                    You are right of course about CT missing many bowel injuries. With a careful evaluation of CT Pancreatic injuries are not usually missed. If it is a very minor injury the findings could be subtle. Rapid U.S of four quadrants is becoming more and more popular in trauma victims to rule out major injuries. DPL has its uses too on occasion. In an unstable patient with no other significant injuries else where, nothing like a Bard Parker #10. In a stable patient observation in the ED for about 4-6 hours will bring to light many bowel injuries. Beware the unconscious or comatose!!

                    "What the mind does not know, the eyes do not see"

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                    • #11
                      I got here late today. I missed the fun.

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                      • #12
                        Don't forget that that is precisely the site of duodenal ulcer in ZE syndrome.

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                        • #13
                          We want MORE PUZZLES!

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                          • #14
                            I think Robodoc has not visited in a few days
                            Bigdoc

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                            • #15
                              Robodoc's last post was on 4/23. I gues he deserves a weekend off from everything? Or he may be busy putting together another series of ED puzzles for all of us

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