European Journal of Internal Medicine 26 (2015) e3–e4
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
A man with acute epigastric pain Shing Ching ⁎, Ka Hing Lee, Kai Ming Li Accident and Emergency Department, United Christian Hospital, Hong Kong, China
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Article history: Received 18 August 2014 Accepted 15 September 2014 Available online 29 September 2014
1. Indication A 68-year-old man with history of hypertension presented with 1 day of epigastric pain, vomiting and chills. Physical examination was notable for a febrile, toxic-looking patient in distress; there was epigastric tenderness and guarding. Per rectal exam found guaiac-negative stool. A sitting chest X-ray was taken (Fig. 1). What is the diagnosis?
Fig. 1. Erect chest X-ray of the patient.
⁎ Corresponding author. Tel.: +852 94597789. E-mail address: [email protected] (S. Ching).
http://dx.doi.org/10.1016/j.ejim.2014.09.013 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
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S. Ching et al. / European Journal of Internal Medicine 26 (2015) e3–e4
2. Diagnosis Diagnosis: perforated peptic ulcer. The sitting chest X-ray showed a thin rim of air sandwiched between the left hemidiaphragm and the gastric wall. A subsequent noncontrast computer tomography of the abdomen confirmed the diagnosis. Intraperitoneal free gas is best seen between the right hemidiaphragm and the liver. The juxtaposition of a radio-opaque organ and gas creates excellent contrast for its detection. However, the left hemidiaphragm is frequently overlooked. Free gas in this area separates the diaphragm from the gastric wall, making either unusually thin that would alert the astute. The sensitivity of erect chest X-ray improves with greater amount of pneumoperitoneum [1], therefore
the absence of free gas does not exclude the diagnosis under probable clinical circumstance.
Conflict of interests The authors report no conflict of interesting regarding this work.
Reference [1] Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16(5):713–6.
Contents lists available at ScienceDirect
European Journal of Internal Medicine journal homepage: www.elsevier.com/locate/ejim
Internal Medicine Flashcard
A man with acute epigastric pain Shing Ching ⁎, Ka Hing Lee, Kai Ming Li Accident and Emergency Department, United Christian Hospital, Hong Kong, China
a r t i c l e
i n f o
Article history: Received 18 August 2014 Accepted 15 September 2014 Available online 29 September 2014
1. Indication A 68-year-old man with history of hypertension presented with 1 day of epigastric pain, vomiting and chills. Physical examination was notable for a febrile, toxic-looking patient in distress; there was epigastric tenderness and guarding. Per rectal exam found guaiac-negative stool. A sitting chest X-ray was taken (Fig. 1). What is the diagnosis?
Fig. 1. Erect chest X-ray of the patient.
⁎ Corresponding author. Tel.: +852 94597789. E-mail address: [email protected] (S. Ching).
http://dx.doi.org/10.1016/j.ejim.2014.09.013 0953-6205/© 2014 European Federation of Internal Medicine. Published by Elsevier B.V. All rights reserved.
e4
S. Ching et al. / European Journal of Internal Medicine 26 (2015) e3–e4
2. Diagnosis Diagnosis: perforated peptic ulcer. The sitting chest X-ray showed a thin rim of air sandwiched between the left hemidiaphragm and the gastric wall. A subsequent noncontrast computer tomography of the abdomen confirmed the diagnosis. Intraperitoneal free gas is best seen between the right hemidiaphragm and the liver. The juxtaposition of a radio-opaque organ and gas creates excellent contrast for its detection. However, the left hemidiaphragm is frequently overlooked. Free gas in this area separates the diaphragm from the gastric wall, making either unusually thin that would alert the astute. The sensitivity of erect chest X-ray improves with greater amount of pneumoperitoneum [1], therefore
the absence of free gas does not exclude the diagnosis under probable clinical circumstance.
Conflict of interests The authors report no conflict of interesting regarding this work.
Reference [1] Stapakis JC, Thickman D. Diagnosis of pneumoperitoneum: abdominal CT vs. upright chest film. J Comput Assist Tomogr 1992;16(5):713–6.
