iEM Image Feed: Viscus perforation

iem image feed

A 35 years old previously healthy gentleman presented to the Emergency Department with a sudden-onset severe and diffuse abdominal pain which started an hour ago. Chest X-ray was ordered; what do you see?

Abdominal pain is one of the commonest ED presentations. Like acute MI, AAA rupture, or DKA, viscus perforation should be in our worst-case scenario list. The image shows free air under the diaphragm.

The expected hints for this type of patient are a history of peptic/duodenal ulcer disease, severe abdominal pain that patients do not want to move, and a rigid and very tender abdomen, which any palpation gives much pain to the patient. 

We need to remember that this situation is a surgical emergency. There are some steps that we need to do immediately for this patient.

  1. Proper history and examination
  2. Attaching to monitor and following vital signs and intervene if necessary to normalize them
  3. Opening 2 large-bore IV lines and fluid resuscitation as needed
  4. IV pain medication
  5. IV antibiotics
  6. Stopping oral ingestion and placing NG tube
  7. Contact surgery
  8. Sending basic biochemistry lab, coagulation profile, blood type and cross, CBC, which will be asked by surgery soon. 
  9. Arranging transfer to the OR
887.1 - viscus perforation

Abdominal pain is one of the commonest ED presentations. Like acute MI, AAA rupture, or DKA, viscus perforation should be in our worst-case scenario list. The image shows free air under the diaphragm.

887.2 - viscus perforation

The expected hints for this type of patient are a history of peptic/duodenal ulcer disease, severe abdominal pain that patients do not want to move, and a rigid and very tender abdomen, which any palpation gives much pain to the patient. 

We need to remember that this situation is a surgical emergency. There are some steps that we need to do immediately for this patient.

  1. Proper history and examination
  2. Attaching to monitor and following vital signs and intervene if necessary to normalize them
  3. Opening 2 large-bore IV lines and fluid resuscitation as needed
  4. IV pain medication
  5. IV antibiotics
  6. Stopping oral ingestion and placing NG tube
  7. Contact surgery
  8. Sending basic biochemistry lab, coagulation profile, blood type and cross, CBC, which will be asked by surgery soon. 
  9. Arranging transfer to the OR

Additional reading

Cite this article as: iEM Education Project Team, "iEM Image Feed: Viscus perforation," in International Emergency Medicine Education Project, April 14, 2021, https://iem-student.org/2021/04/14/viscus-perforation/, date accessed: June 20, 2021

Siedel Test

A 42 years old male, presents to the ED 1 hour after he was hammering a nail onto a wooden shelf, where the nail flew and strike his left open eye. In an attempt to help, his friend immediately removed the nail. After that, he has been having severe sharp pain and blurry vision in his left eye. On examination, the left eye had poor visual acuity, and he could only perceive light and movement. The pupil was fixed, dilated and non-reactive to light. Right eye examination was normal.

819.2 - eye penetran trauma 2 -siedel sign
819.1 - eye penetran trauma 1

How would you approach to this patient?

To learn more about it, read chapters below.

Read "Eye Trauma" Chapter

Read "Red Eye" Chapter

Quick Read

Globe rupture

It is an ophthalmologic emergency, consisting of a full-thickness injury in the cornea or sclera caused by penetrating or blunt trauma. Anterior rupture is usually observed, as this is the region where the sclera is the thinnest. Posterior rupture is rare and difficult to diagnose. It can be diagnosed through indirect findings such as contraction in the anterior chamber and decrease in intraocular pressure (IOP) in the affected eye. If there is a risk of globe rupture, a slit lamp test with 10% fluorescein must be conducted. Normal tissue is dark orange under a blue cobalt filter; a lighter color is observed in the damaged zone due to a lower dye concentration. Ultrasonography (USG) can be useful in making a diagnosis, especially with posterior ruptures. Computed tomography (CT) sensitivity ranges 56–75%. In cases of anterior globe injuries, USG use, and if there is a risk of a foreign metal body, magnetic resonance imaging, are contraindicated. Prompt ophthalmology consultation is required. While in the emergency department, tetanus prophylaxis, analgesics, bed rest, head elevation, and systemic antibiotic therapy are required. The most commonly preferred antibiotics are cefazolin and vancomycin. Age over 60 years; injury sustained by assault, on the street/highway, during a fall, or by gunshot; and posterior injuries are indications of a poor prognosis.

Siedel test

Seidel test is used to detect ocular leaks from the globe following injury. If there is penetration to the eye, aqueous leakage happens. However, the fluid is clear and hard to identify. Therefore, non-invasive test “Siedel” is used for better visualization of this leakage. Fluorescein 10% is applied to the injured eye, and the leakage becomes more prominent.

To learn more about it, read chapters below.

Read "Eye Trauma" Chapter

Read "Red Eye" Chapter

56-years-old male presented with chest pain.

716 - perforated ulcer

56 years old male known case of HTN, presented to ED with chest pain. The onset was 2 hours ago started gradually. It is a constant and worsening pain. Location: Anterior central chest epigastric. Radiating to Central back” middle of the back.” The character of the pain is heaviness and tightness. The degree at onset was 3 /10. The degree at maximum was 6 /10. The Exacerbating factor is leaning forward. The relieving factor is rest but not leaning forward, eating, antacids, oxygen, nitroglycerin, and morphine sulfate.

Do you recognize the problem in the chest x-ray?

To learn about management, please read chapter below.

Perforated Viscus by Ozlem Dikme

Don’t Touch My Belly!

A New Chapter Is Just Uploaded To The Website!

A previously healthy 42-year-old male presented to the Emergency Department (ED) with a 3-day history of worsening abdominal pain. He felt nauseated and vomited twice. His pain started around the umbilicus, moved to the left side of his abdomen and then become generalized. It peaked the last few hours, and the painkillers did not work. His social history revealed that he was non-drinker, non-smoker and did not use any illicit drugs. The past and family histories were unremarkable. His blood pressure was 100/60 mmHg, pulse rate 120/min, the temperature 37.8°C (100°F), and respiration rate 24/min. Physical examination showed diffuse abdominal tenderness and voluntary guarding. Bowel sounds were not heard. 

52 - Perforated Viscus

Bedside ultrasonography (USG) exhibited increased echogenicity of the peritoneal stripe, with corresponding horizontal reverberation artifacts over the liver. Plain chest radiographs confirmed the presence of free abdominal air. Oral intake was stopped, intravenous (IV) catheter was inserted, fluid therapy was started, and cefoperazone sodium was administered intravenously. Blood type and cross, complete blood count and coagulation were ordered. He transferred to the operation theater with the diagnosis of the perforated viscus.

Turkey
by Ozlem Dikme from Turkey.