American Journal of Emergency Medicine 32 (2014) 288.e5–288.e6
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Early diagnosis of pneumoperitoneum in bowel perforation by capnography: a report of 2 cases☆,☆☆,★ Abstract Capnography is commonly used for monitoring purposes. Here, we describe a new application of capnography as a bedside diagnostic modality. In doubtful situations of pneumoperitoneum, intravenous cannula is inserted in abdominal cavity, and capnography wave forms are detected with the help of gas sampling port. Capnography can detect pneumoperitoneum of bowel origin quickly and efficiently when radiology and clinical diagnosis are inconclusive. It can also detect gas in supine position. This technique is useful even in doubtful cases of pneumoperitoneum differentiating from pseudopneumoperitoneum. Noniatrogenic pneumoperitoneum commonly resulted from a perforated hollow viscus in 90% of cases, usually of small and large bowel [1]. These conditions are conventionally diagnosed clinically, that is, obliteration of liver dullness or, radiologically, gas under diaphragm [2]. High skill is required to interpret the radiology film at times where the cases are not so straightforward. In addition, radiography images may miss pneumoperitoneum or retroperitoneum in up to 49% of patients [3]. Many patients with acute abdominal pain cannot stand to have an erect chest radiograph. Again, clinical methods also require good clinical expertise. Here, we described a quick bedside diagnostic modality for pneumoperitoneum using capnography even where radiological diagnosis is doubtful. We have taken consents from both the patients before the procedure as well as for reporting the same. In patient with high clinical suspicion and history suggestive of bowel perforation, we can use this simple quick technique to detect pneumoperitoneum at bedside. Patient should lie in semi-upright position with the hand kept above the head. We point out the puncture site by clinical percussion at midpoint of obliteration of liver dullness on midaxillary line using a marking pen. Then after proper antiseptic dressing with alcohol-based chlorhexidine solution and sterile draping, we introduced 20G intravenous catheter at the puncture point marked beforehand (Fig. 1). We attached capnography sample line to the inserted cannula after removing its stylet. In case of pneumoperitoneum due to bowel perforation with the movement of diaphragm, subdiaphragmatic gas derived from intestine containing carbon dioxide was detected in the monitor as gas moves in the sample line (Fig. 2).
☆ Source(s) of support: None. ☆☆ Presentation at a meeting: None. ★ Conflicting interest: None. 0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
A 34-year-old male known alcoholic and chronic smoker was admitted in our emergency department (ED) with complained of pain in the abdomen for 2 days and altered sensorium for 1 day. Abdominal examination revealed generalized tenderness, obliteration of liver dullness, and absent bowel sounds. With the clinical suspicion of bowel perforation, x-ray abdomen in erect posture was advised. The patient was too sick to stand up erect due to pain or to be shifted to the radiology department. So, 20° upright abdominal x- ray was taken at bedside. However, diagnosis of pneumoperitoneum remained doubtful due to superimposed large bowel gas shadows. We applied our method by puncturing the abdominal wall with 20G intravenous catheter along the midaxillary line in right sixth intercostal space in aseptic manner, as described above. With the movement of diaphragm, gases accumulated in the side of abdominal cavity also moved and reflected in the capnography graph. A 23-year-old man admitted in our ED with polytrauma with blunt trauma abdomen (suspected bowel injury) with lower extremities fractures. He was unable to stand up. In this case also, we did the same aforementioned method to detect pneumoperitoneum. Capnography waveform was nicely visible. Bowel perforations resulted from various causes such as peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, foreign body, or a neoplasm. It often requires rapid diagnosis and surgical treatment subsequently. To interpret pneumoperitoneum correctly, it requires an upright radiological film where free gas being collected at the most superior position, usually subdiaphragmatic area. In other positions, detection of free gas is very difficult due to superimposed bowel gas shadows. Overdistension of hollow viscera, undulating configuration of the diaphragm causing the basal
Fig. 1. A 20G intravenous cannula inserted along the midaxillary line in strict aseptic precaution.
288.e6
S. Samanta, S. Samanta / American Journal of Emergency Medicine 32 (2014) 288.e5–288.e6
ing pneumoperitoneum due to bowel perforation of different etiology in 2 patients successfully. We found this technique useful even in doubtful cases of pneumoperitoneum differentiating from pseudopneumoperitoneum. However, before recommending this unique bedside technique as a routine in the ED, a randomized controlled trial is warranted in large scale of patients comparing with the conventional radiological methods exploring its several aspects of efficacy and safety.
Acknowledgment Prof G D Puri, Department of Anesthesia and Intensive Care, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012.
Sukhen Samanta MD Department of Anesthesia & Critical Care(Trauma Centre) JPNA Trauma Centre, AIIMS New Delhi 110029, India E-mail address: [email protected]
Fig. 2. Capnography waveform with movement of diaphragm due to carbon dioxide in peritoneal cavity.
lung to appear lying below the diaphragm, subdiaphragmatic extraperitoneal fat, and interposition of the hepatic flexure of the colon between the right lobe of the liver and the diaphragm can all simulate pneumoperitoneum—causing pseudopneumoperitoneum [4]. Recently ultrasonography had been used as an initial diagnostic test to determine presence as well as the cause of the pneumoperitoneum [5]. However, it requires high skills of the operator including difficulty in situations like obesity, patients with subcutaneous emphysema, and poor-quality images. Undoubtedly, computed tomography detects the site of perforation more accurately, but it often required shifting of critical ill patients. Capnography is a well-established monitoring tool not only for ventilation but also for circulation and metabolism [6]. As time progresses, uses of capnography are being explored in many unique areas of medical field. Most of the gas present in the gastrointestinal tract of normal adults is composed of 5 gases: nitrogen (N2), oxygen (O2), carbon dioxide (CO2), hydrogen (H2), and methane (CH4). Carbon dioxide presents in intestinal gases as 4% in stomach, 5.1% to 29% in intestine, and 3% to 54% in flatus [7,8]. There are regular movements of gases in gastrointestinal tract lumen from stomach to small intestine and large intestine. Normal exhaled gas contains approximately 4% CO2. So the percentage of CO2 in bowel air is fair enough to be detected in capnography. We used the unique capnographic method of detect-
Sujay Samanta MD Department of Critical Care Medicine Sanjay Gandhi Post Graduate Institute of Medical Sciences Luckow 226014, India http://dx.doi.org/10.1016/j.ajem.2013.09.039
References [1] Hillman KM. Pneumoperitoneum—a review. Crit Care Med 1982;10:476–81. [2] Roh JJ, Thompson JS, Harned RK, et al. Value of pneumoperitoneum in the diagnosis of visceral perforation. Am J Surg 1983;5:830–3. [3] Hefny AF, Abu-Zidan FM. Sonographic diagnosis of intraperitoneal free air. J Emerg Trauma Shock 2011;5:511–3. [4] Miller RE, Nelson SW. The roentgenologic demonstration of tiny amounts of free intraperitoneal gas; experimental and clinical studies. Am J Roentgenol Radiat Nucl Ther 1971;112:574–85. [5] Coppolino F, Gatta G, Di Grezia G, et al. Gastrointestinal perforation: ultrasonographic diagnosis. Crit Ultrasound J 2013;15(5 Suppl 1):S4 15. [6] Gravenstein JS, Jaffe MB, Gravenstein N, Paulus DA, editors. Capnography. 2nd Edn. Cambridge: Cambridge University Press; 2011. p. 474. [7] Levitt MD. Volume and composition of human intestinal gas determined by means of an intestinal washout technic. N Engl J Med 1971;284:1394–8. [8] Levitt MD, Bond Jr H. Volume, composition, and source of intestinal gas. Gastroenterology 1970;59:921–9.
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
Early diagnosis of pneumoperitoneum in bowel perforation by capnography: a report of 2 cases☆,☆☆,★ Abstract Capnography is commonly used for monitoring purposes. Here, we describe a new application of capnography as a bedside diagnostic modality. In doubtful situations of pneumoperitoneum, intravenous cannula is inserted in abdominal cavity, and capnography wave forms are detected with the help of gas sampling port. Capnography can detect pneumoperitoneum of bowel origin quickly and efficiently when radiology and clinical diagnosis are inconclusive. It can also detect gas in supine position. This technique is useful even in doubtful cases of pneumoperitoneum differentiating from pseudopneumoperitoneum. Noniatrogenic pneumoperitoneum commonly resulted from a perforated hollow viscus in 90% of cases, usually of small and large bowel [1]. These conditions are conventionally diagnosed clinically, that is, obliteration of liver dullness or, radiologically, gas under diaphragm [2]. High skill is required to interpret the radiology film at times where the cases are not so straightforward. In addition, radiography images may miss pneumoperitoneum or retroperitoneum in up to 49% of patients [3]. Many patients with acute abdominal pain cannot stand to have an erect chest radiograph. Again, clinical methods also require good clinical expertise. Here, we described a quick bedside diagnostic modality for pneumoperitoneum using capnography even where radiological diagnosis is doubtful. We have taken consents from both the patients before the procedure as well as for reporting the same. In patient with high clinical suspicion and history suggestive of bowel perforation, we can use this simple quick technique to detect pneumoperitoneum at bedside. Patient should lie in semi-upright position with the hand kept above the head. We point out the puncture site by clinical percussion at midpoint of obliteration of liver dullness on midaxillary line using a marking pen. Then after proper antiseptic dressing with alcohol-based chlorhexidine solution and sterile draping, we introduced 20G intravenous catheter at the puncture point marked beforehand (Fig. 1). We attached capnography sample line to the inserted cannula after removing its stylet. In case of pneumoperitoneum due to bowel perforation with the movement of diaphragm, subdiaphragmatic gas derived from intestine containing carbon dioxide was detected in the monitor as gas moves in the sample line (Fig. 2).
☆ Source(s) of support: None. ☆☆ Presentation at a meeting: None. ★ Conflicting interest: None. 0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
A 34-year-old male known alcoholic and chronic smoker was admitted in our emergency department (ED) with complained of pain in the abdomen for 2 days and altered sensorium for 1 day. Abdominal examination revealed generalized tenderness, obliteration of liver dullness, and absent bowel sounds. With the clinical suspicion of bowel perforation, x-ray abdomen in erect posture was advised. The patient was too sick to stand up erect due to pain or to be shifted to the radiology department. So, 20° upright abdominal x- ray was taken at bedside. However, diagnosis of pneumoperitoneum remained doubtful due to superimposed large bowel gas shadows. We applied our method by puncturing the abdominal wall with 20G intravenous catheter along the midaxillary line in right sixth intercostal space in aseptic manner, as described above. With the movement of diaphragm, gases accumulated in the side of abdominal cavity also moved and reflected in the capnography graph. A 23-year-old man admitted in our ED with polytrauma with blunt trauma abdomen (suspected bowel injury) with lower extremities fractures. He was unable to stand up. In this case also, we did the same aforementioned method to detect pneumoperitoneum. Capnography waveform was nicely visible. Bowel perforations resulted from various causes such as peptic ulcer, inflammatory disease, blunt or penetrating trauma, iatrogenic factors, foreign body, or a neoplasm. It often requires rapid diagnosis and surgical treatment subsequently. To interpret pneumoperitoneum correctly, it requires an upright radiological film where free gas being collected at the most superior position, usually subdiaphragmatic area. In other positions, detection of free gas is very difficult due to superimposed bowel gas shadows. Overdistension of hollow viscera, undulating configuration of the diaphragm causing the basal
Fig. 1. A 20G intravenous cannula inserted along the midaxillary line in strict aseptic precaution.
288.e6
S. Samanta, S. Samanta / American Journal of Emergency Medicine 32 (2014) 288.e5–288.e6
ing pneumoperitoneum due to bowel perforation of different etiology in 2 patients successfully. We found this technique useful even in doubtful cases of pneumoperitoneum differentiating from pseudopneumoperitoneum. However, before recommending this unique bedside technique as a routine in the ED, a randomized controlled trial is warranted in large scale of patients comparing with the conventional radiological methods exploring its several aspects of efficacy and safety.
Acknowledgment Prof G D Puri, Department of Anesthesia and Intensive Care, Advanced Cardiac Centre, Post Graduate Institute of Medical Education and Research, Chandigarh, India, 160012.
Sukhen Samanta MD Department of Anesthesia & Critical Care(Trauma Centre) JPNA Trauma Centre, AIIMS New Delhi 110029, India E-mail address: [email protected]
Fig. 2. Capnography waveform with movement of diaphragm due to carbon dioxide in peritoneal cavity.
lung to appear lying below the diaphragm, subdiaphragmatic extraperitoneal fat, and interposition of the hepatic flexure of the colon between the right lobe of the liver and the diaphragm can all simulate pneumoperitoneum—causing pseudopneumoperitoneum [4]. Recently ultrasonography had been used as an initial diagnostic test to determine presence as well as the cause of the pneumoperitoneum [5]. However, it requires high skills of the operator including difficulty in situations like obesity, patients with subcutaneous emphysema, and poor-quality images. Undoubtedly, computed tomography detects the site of perforation more accurately, but it often required shifting of critical ill patients. Capnography is a well-established monitoring tool not only for ventilation but also for circulation and metabolism [6]. As time progresses, uses of capnography are being explored in many unique areas of medical field. Most of the gas present in the gastrointestinal tract of normal adults is composed of 5 gases: nitrogen (N2), oxygen (O2), carbon dioxide (CO2), hydrogen (H2), and methane (CH4). Carbon dioxide presents in intestinal gases as 4% in stomach, 5.1% to 29% in intestine, and 3% to 54% in flatus [7,8]. There are regular movements of gases in gastrointestinal tract lumen from stomach to small intestine and large intestine. Normal exhaled gas contains approximately 4% CO2. So the percentage of CO2 in bowel air is fair enough to be detected in capnography. We used the unique capnographic method of detect-
Sujay Samanta MD Department of Critical Care Medicine Sanjay Gandhi Post Graduate Institute of Medical Sciences Luckow 226014, India http://dx.doi.org/10.1016/j.ajem.2013.09.039
References [1] Hillman KM. Pneumoperitoneum—a review. Crit Care Med 1982;10:476–81. [2] Roh JJ, Thompson JS, Harned RK, et al. Value of pneumoperitoneum in the diagnosis of visceral perforation. Am J Surg 1983;5:830–3. [3] Hefny AF, Abu-Zidan FM. Sonographic diagnosis of intraperitoneal free air. J Emerg Trauma Shock 2011;5:511–3. [4] Miller RE, Nelson SW. The roentgenologic demonstration of tiny amounts of free intraperitoneal gas; experimental and clinical studies. Am J Roentgenol Radiat Nucl Ther 1971;112:574–85. [5] Coppolino F, Gatta G, Di Grezia G, et al. Gastrointestinal perforation: ultrasonographic diagnosis. Crit Ultrasound J 2013;15(5 Suppl 1):S4 15. [6] Gravenstein JS, Jaffe MB, Gravenstein N, Paulus DA, editors. Capnography. 2nd Edn. Cambridge: Cambridge University Press; 2011. p. 474. [7] Levitt MD. Volume and composition of human intestinal gas determined by means of an intestinal washout technic. N Engl J Med 1971;284:1394–8. [8] Levitt MD, Bond Jr H. Volume, composition, and source of intestinal gas. Gastroenterology 1970;59:921–9.
