Downloaded from http://emj.bmj.com/ on July 20, 2015 - Published by group.bmj.com
Images in emergency medicine
Coffee ground vomitus in 84-year-old male An 84-year-old man presented to our emergency department because of coffee ground vomitus over several days. Physical examination revealed right scrotal swelling with crepitus (figure 1). kidney, ureter, bladder (KUB) radiography (figure 2) was arranged; however, 2 h later, his condition deteriorated. CT revealed extensive pneumoretroperitoneum extending from the posterior surface of the liver down to the right inguinal canal (figure 3). Emergent surgery was performed, which revealed retroperitoneal abscess due to duodenal perforation. Unfortunately, he expired the next day due to septic shock. Retroperitoneal abscess poses a diagnostic challenge because of non-specific presentation. Plain films usually provide the first hint
Figure 3 CT showed the extraluminal gas surrounding the duodenum (asterisk) and spreading down to the right inguinal canal. of this disease, although CT is the best imaging modality for evaluation. Here, KUB showed the absence of the right psoas shadow, indicating a pathological disturbance. Furthermore, an unusual air pattern was identified in the right paraspinal area (figure 2, arrows). Duodenal perforation can result in pneumoretroperitoneum. Yagan et al1 suggested that air in the right perinephric space should alert the physician to the possibility of duodenal perforation. In our case, the duodenum (figure 3, asterisk) was surrounded by extraluminal gas that spread within the anterior and posterior pararenal spaces, indicating duodenal perforation as the aetiology of retroperitoneal abscess. Mingtse Tsai,1 Jiannming Wu,2 Chanping Su1 1
Figure 1 The picture shows right scrotal swelling.
Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan 2 Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan Correspondence to Dr Mingtse Tsai, Department of Emergency Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya South Road, Banciao District, New Taipei City 22060, Taiwan; [email protected] Contributors CS was the primary physician who provided care to the patient in the emergency room. JW was the surgeon who found the ulcer was the real cause of shock and retroperitoneal abscess. MT was responsible for data collection and article submission. MT, 12 December 2013. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Tsai M, Wu J, Su C. Emerg Med J 2015;32:668. Accepted 22 January 2014 Published Online First 25 February 2014 Emerg Med J 2015;32:668. doi:10.1136/emermed-2013-203508
Figure 2 KUB showed the absence of the right psoas shadow, indicating a pathological disturbance over that area. Pay attention to the unusual air pattern in the right paraspinal area (arrows). 668
REFERENCE 1
Yagan N, Auh YH, Fisher A. Extension of air into the right perirenal space after duodenal perforation: CT findings. Radiology 2009;250:740–8.
Tsai M, et al. Emerg Med J August 2015 Vol 32 No 8
Downloaded from http://emj.bmj.com/ on July 20, 2015 - Published by group.bmj.com
Coffee ground vomitus in 84-year-old male Mingtse Tsai, Jiannming Wu and Chanping Su Emerg Med J 2015 32: 668 originally published online February 25, 2014
doi: 10.1136/emermed-2013-203508 Updated information and services can be found at: http://emj.bmj.com/content/32/8/668
These include:
References Email alerting service
Topic Collections
This article cites 1 articles, 0 of which you can access for free at: http://emj.bmj.com/content/32/8/668#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Trauma (996) Ethics (372) Clinical diagnostic tests (996) Radiology (945) Radiology (diagnostics) (852)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
Images in emergency medicine
Coffee ground vomitus in 84-year-old male An 84-year-old man presented to our emergency department because of coffee ground vomitus over several days. Physical examination revealed right scrotal swelling with crepitus (figure 1). kidney, ureter, bladder (KUB) radiography (figure 2) was arranged; however, 2 h later, his condition deteriorated. CT revealed extensive pneumoretroperitoneum extending from the posterior surface of the liver down to the right inguinal canal (figure 3). Emergent surgery was performed, which revealed retroperitoneal abscess due to duodenal perforation. Unfortunately, he expired the next day due to septic shock. Retroperitoneal abscess poses a diagnostic challenge because of non-specific presentation. Plain films usually provide the first hint
Figure 3 CT showed the extraluminal gas surrounding the duodenum (asterisk) and spreading down to the right inguinal canal. of this disease, although CT is the best imaging modality for evaluation. Here, KUB showed the absence of the right psoas shadow, indicating a pathological disturbance. Furthermore, an unusual air pattern was identified in the right paraspinal area (figure 2, arrows). Duodenal perforation can result in pneumoretroperitoneum. Yagan et al1 suggested that air in the right perinephric space should alert the physician to the possibility of duodenal perforation. In our case, the duodenum (figure 3, asterisk) was surrounded by extraluminal gas that spread within the anterior and posterior pararenal spaces, indicating duodenal perforation as the aetiology of retroperitoneal abscess. Mingtse Tsai,1 Jiannming Wu,2 Chanping Su1 1
Figure 1 The picture shows right scrotal swelling.
Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan 2 Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan Correspondence to Dr Mingtse Tsai, Department of Emergency Medicine, Far Eastern Memorial Hospital, No. 21, Sec. 2, Nanya South Road, Banciao District, New Taipei City 22060, Taiwan; [email protected] Contributors CS was the primary physician who provided care to the patient in the emergency room. JW was the surgeon who found the ulcer was the real cause of shock and retroperitoneal abscess. MT was responsible for data collection and article submission. MT, 12 December 2013. Competing interests None. Patient consent Obtained. Provenance and peer review Not commissioned; internally peer reviewed.
To cite Tsai M, Wu J, Su C. Emerg Med J 2015;32:668. Accepted 22 January 2014 Published Online First 25 February 2014 Emerg Med J 2015;32:668. doi:10.1136/emermed-2013-203508
Figure 2 KUB showed the absence of the right psoas shadow, indicating a pathological disturbance over that area. Pay attention to the unusual air pattern in the right paraspinal area (arrows). 668
REFERENCE 1
Yagan N, Auh YH, Fisher A. Extension of air into the right perirenal space after duodenal perforation: CT findings. Radiology 2009;250:740–8.
Tsai M, et al. Emerg Med J August 2015 Vol 32 No 8
Downloaded from http://emj.bmj.com/ on July 20, 2015 - Published by group.bmj.com
Coffee ground vomitus in 84-year-old male Mingtse Tsai, Jiannming Wu and Chanping Su Emerg Med J 2015 32: 668 originally published online February 25, 2014
doi: 10.1136/emermed-2013-203508 Updated information and services can be found at: http://emj.bmj.com/content/32/8/668
These include:
References Email alerting service
Topic Collections
This article cites 1 articles, 0 of which you can access for free at: http://emj.bmj.com/content/32/8/668#BIBL Receive free email alerts when new articles cite this article. Sign up in the box at the top right corner of the online article.
Articles on similar topics can be found in the following collections Trauma (996) Ethics (372) Clinical diagnostic tests (996) Radiology (945) Radiology (diagnostics) (852)
Notes
To request permissions go to: http://group.bmj.com/group/rights-licensing/permissions To order reprints go to: http://journals.bmj.com/cgi/reprintform To subscribe to BMJ go to: http://group.bmj.com/subscribe/
