Page 27 - Delaware Medical Journal - July 2016
P. 27
CASE REPORT
and increasing peak pressures on the ventilator. The patient
was stabilized with needle decompression and placement of
a thoracotomy tube. A subsequent chest x-ray (Figure 3) demonstrated extensive subcutaneous air and pneumoperitoneum. Additionally, the patient was noted to have increasing abdominal distension and tympany on physical examination. CT imaging of the chest and abdomen was then obtained, which demonstrated a large amount of free intraperitoneal air exerting mass effect on the underlying abdominal organs (Figure 4A, B, and C). The exact was seen tracking along the ventral abdominal wall and along
the falciform ligament, raising possibility of an entry tract to the peritoneal cavity. Based on the patient’s clinical status and physical examination, decision was made to perform emergent needle decompression. Patient had a prolonged hospital course with continued clinical improvement and eventual extubation to BiPAP and discharge to home.
DISCUSSION
Tension pneumoperitoneum, or alternatively hyperacute abdominal compartment syndrome, is a rare complication of pneumoperitoneum.1 Pneumoperitoneum inning of itself is a benign process which may result from various insults, such as recent intra-abdominal surgery, gastrointestinal perforation, colonoscopy/endoscopy, and mechanical ventilation.2 Additionally, CPR is a known but rare cause of pneumoperitoneum.3 Tension pneumoperitoneum, like tension pneumothorax, is mostly
a clinical diagnosis that results when pneumoperitoneum
exerts mass effect on intra-abdominal structures, resulting in ventilatory and hemodynamic compromise.2 The life threatening complications of tension pneumoperitoneum result from elevation of the hemidiaphragm and increased intra-abdominal pressure, which restricts lung volumes and decreases venous return, cardiac output, stroke volume, and arterial PO .2
2
pneumoperitoneum, including continuous diaphragm sign,
sign of tension pneumoperitoneum is the “saddle bag” sign,
displacement of the diaphragm.2 Urgent CT imaging can be obtained when the diagnosis may be unclear due to overlying subcutaneous emphysema. Findings on CT may include
massive pneumoperitoneum with bowel loop compression and centralization of abdominal organs. Once tension pneumothorax is recognized, it is recommended that urgent abdominal needle
FIGURE 3
AP x-ray of the chest, utilizing an edge enhancing algorithm, demonstrating right apical chest tube with diffuse subcutaneous emphysema and pneumoperitoneum. Solid white arrows along the diaphragmatic edge highlight an example of “continuous diaphragm sign”.
FIGURE 4A
Axial CT image of the upper chest on lung windows demonstrating superiorly visualized extent of subcutaneous emphysema.
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