The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.07.061
Visual Diagnosis in Emergency Medicine
TENSION PNEUMOPERITONEUM IN A LUNG CANCER PATIENT WITH INTESTINAL METASTASES Yu-Guang Chen, MD, Jia-Hong Chen, MD, and Tzu-Chuan Huang, MD Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC Reprint Address: Tzu-Chuan Huang, MD, Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
air causing hemodynamic instability and circulatory collapse. The patient succumbed to the disease course 1 day later due to the palliative will of the family.
CASE REPORT A 65-year-old man, diagnosed with metastatic adenocarcinoma of the lung 5 months earlier, presented to the emergency department (ED) with persistent abdominal fullness and intractable pain. About 3 months earlier, he had experienced repeated hematochezia, and the intestinal metastasis was diagnosed after colorectoscopy examination. Subsequently, he had repeatedly experienced intermittent abdominal fullness, nausea, and vomiting due to intestinal metastases-related intestinal obstruction. His disease status showed no regression despite targeted oral therapy with erlotinib administration in the period from diagnosis to the present. On arrival, the patient was febrile, tachycardic (145 beats/min), and in shock (blood pressure of 70/45 mm Hg). Physical examination showed a distended, tympanic abdomen with overt peritoneal signs. The abdominal plain film demonstrated specific signs including visible distended bowel walls on both sides (Rigler’s sign, double wall sign) and hyperlucent liver signs (Figure 1). A large oval radiolucency in the shape of the whole abdominal wall was also found (football-like sign). A computed tomography scan revealed massive accumulation of intra-abdominal free air and air-fluid level appearance (Figure 2). The tension pneumoperitoneum was confirmed by definition: massive intra-abdominal free
Figure 1. Plain film of the abdomen shows both sides of the bowel wall visualized (double wall sign, black arrow), as well as the football sign (white arrow), and the hyperlucent hepatic sign.
RECEIVED: 5 March 2014; FINAL SUBMISSION RECEIVED: 20 June 2014; ACCEPTED: 1 July 2014 1
2
Y.-G. Chen et al.
Figure 2. Computed tomography scan of the abdomen shows massive gas accumulation and air-fluid level formation.
incidence rate of only about 0.5–10% in lung cancer. These cases, as reported in the literature, have been diagnosed by serial imaging studies including endoscopy, surgical specimen, or autopsy. They often involve the small bowel, followed by the gastric region, and present with gastrointestinal tract bleeding, intestinal obstruction, or bowel perforation (3). In our patient, the possible mechanisms of bowel perforation could be attributed to uncontrolled disease status with progressive intestinal involvement. In addition, the tyrosine kinase inhibitor plays an important role in bowel perforation because the potent cytotoxic effects on bowel wall are to reepithelialize function or lead to tumor necrosis (4). Generally, the gastrointestinal tract metastases should be considered to be a sign of the terminal disease stage, and we emphasize that emergency physicians should evaluate the possible abdominal complications carefully when lung cancer patients present to the ED with symptoms of acute abdomen. Early recognition of this complication can be useful for diagnosis and immediate management.
DISCUSSION Some valuable imaging signs on abdominal plain film are clues to making an early diagnosis in patients with acute abdomen despite the fact that the abdominal plain x-ray study is neither specific nor sensitive. Some radiographic findings of pneumoperitoneum on supine plain film are the falciform ligament sign, double wall sign, inferior hepatic edge sign, and football sign (1). However, multiple signs of pneumoperitoneum coexisting reveal the presence of massive air in the peritoneum that will result in a medical emergency caused by tension pneumoperitoneum (2). Pulmonary malignancy with gastrointestinal tract metastasis is a relatively rare presentation, with an
REFERENCES 1. Chiu YH, Chen JD, Tiu CM, et al. Reappraisal of radiographic signs of pneumoperitoneum at emergency department. Am J Emerg Med 2009;27:320–7. 2. Lu TC, Chen SY, Wang HP, et al. Tension pneumoperitoneum following upper gastrointestinal endoscopy. J Formos Med Assoc 2006;105:431–3. 3. Rossi G, Marchioni A, Romagnani E, et al. Primary lung cancer presenting with gastrointestinal tract involvement: clinicopathologic and immunohistochemical features in a series of 18 consecutive cases. J Thorac Oncol 2007;2:115–20. 4. Cheon YH, Kim MJ, Kang MG, et al. Bowel perforation after erlotinib treatment in a patient with non-small cell lung cancer. Yonsei Med J 2011;52:695–8.
http://dx.doi.org/10.1016/j.jemermed.2014.07.061
Visual Diagnosis in Emergency Medicine
TENSION PNEUMOPERITONEUM IN A LUNG CANCER PATIENT WITH INTESTINAL METASTASES Yu-Guang Chen, MD, Jia-Hong Chen, MD, and Tzu-Chuan Huang, MD Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC Reprint Address: Tzu-Chuan Huang, MD, Division of Hematology/Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, Taipei, Taiwan, ROC
air causing hemodynamic instability and circulatory collapse. The patient succumbed to the disease course 1 day later due to the palliative will of the family.
CASE REPORT A 65-year-old man, diagnosed with metastatic adenocarcinoma of the lung 5 months earlier, presented to the emergency department (ED) with persistent abdominal fullness and intractable pain. About 3 months earlier, he had experienced repeated hematochezia, and the intestinal metastasis was diagnosed after colorectoscopy examination. Subsequently, he had repeatedly experienced intermittent abdominal fullness, nausea, and vomiting due to intestinal metastases-related intestinal obstruction. His disease status showed no regression despite targeted oral therapy with erlotinib administration in the period from diagnosis to the present. On arrival, the patient was febrile, tachycardic (145 beats/min), and in shock (blood pressure of 70/45 mm Hg). Physical examination showed a distended, tympanic abdomen with overt peritoneal signs. The abdominal plain film demonstrated specific signs including visible distended bowel walls on both sides (Rigler’s sign, double wall sign) and hyperlucent liver signs (Figure 1). A large oval radiolucency in the shape of the whole abdominal wall was also found (football-like sign). A computed tomography scan revealed massive accumulation of intra-abdominal free air and air-fluid level appearance (Figure 2). The tension pneumoperitoneum was confirmed by definition: massive intra-abdominal free
Figure 1. Plain film of the abdomen shows both sides of the bowel wall visualized (double wall sign, black arrow), as well as the football sign (white arrow), and the hyperlucent hepatic sign.
RECEIVED: 5 March 2014; FINAL SUBMISSION RECEIVED: 20 June 2014; ACCEPTED: 1 July 2014 1
2
Y.-G. Chen et al.
Figure 2. Computed tomography scan of the abdomen shows massive gas accumulation and air-fluid level formation.
incidence rate of only about 0.5–10% in lung cancer. These cases, as reported in the literature, have been diagnosed by serial imaging studies including endoscopy, surgical specimen, or autopsy. They often involve the small bowel, followed by the gastric region, and present with gastrointestinal tract bleeding, intestinal obstruction, or bowel perforation (3). In our patient, the possible mechanisms of bowel perforation could be attributed to uncontrolled disease status with progressive intestinal involvement. In addition, the tyrosine kinase inhibitor plays an important role in bowel perforation because the potent cytotoxic effects on bowel wall are to reepithelialize function or lead to tumor necrosis (4). Generally, the gastrointestinal tract metastases should be considered to be a sign of the terminal disease stage, and we emphasize that emergency physicians should evaluate the possible abdominal complications carefully when lung cancer patients present to the ED with symptoms of acute abdomen. Early recognition of this complication can be useful for diagnosis and immediate management.
DISCUSSION Some valuable imaging signs on abdominal plain film are clues to making an early diagnosis in patients with acute abdomen despite the fact that the abdominal plain x-ray study is neither specific nor sensitive. Some radiographic findings of pneumoperitoneum on supine plain film are the falciform ligament sign, double wall sign, inferior hepatic edge sign, and football sign (1). However, multiple signs of pneumoperitoneum coexisting reveal the presence of massive air in the peritoneum that will result in a medical emergency caused by tension pneumoperitoneum (2). Pulmonary malignancy with gastrointestinal tract metastasis is a relatively rare presentation, with an
REFERENCES 1. Chiu YH, Chen JD, Tiu CM, et al. Reappraisal of radiographic signs of pneumoperitoneum at emergency department. Am J Emerg Med 2009;27:320–7. 2. Lu TC, Chen SY, Wang HP, et al. Tension pneumoperitoneum following upper gastrointestinal endoscopy. J Formos Med Assoc 2006;105:431–3. 3. Rossi G, Marchioni A, Romagnani E, et al. Primary lung cancer presenting with gastrointestinal tract involvement: clinicopathologic and immunohistochemical features in a series of 18 consecutive cases. J Thorac Oncol 2007;2:115–20. 4. Cheon YH, Kim MJ, Kang MG, et al. Bowel perforation after erlotinib treatment in a patient with non-small cell lung cancer. Yonsei Med J 2011;52:695–8.
