Not what was expected ... but what was?

10/10/2017

Posted by Dan Crompton

This 31 year old female presented at 12:30 to a sub-tertiary emergency department. Brought in by ambulance complaining of feeling generally unwell with chest and abdominal pains. She had seen her GP a week prior and was diagnosed with influenza.

Further history revealed having fevers and sweats and she denied opening her bowels for 2 days and had pain in the RIF. She denied vomiting, previous PID and pregnancy.

Her observations on arrival were:

P 140 BP123/70 RR 20 Sa O2 98% - room air
Temp 38.5 GCS 14 (V4)

PMH
IVDU - currently using - Ice and amphetamines
Renal Failure - undifferentiated
Pancreatitis
Cholecystectomy
Bipolar disorder
Personality disorder
Chronic chest pain following MVA 10 years ago

Triaged Category 3 and assigned to a cubicle. She was seen by a doctor 105 minutes after arriving.

On exam she had stigmata of recent IVDU. Abdomen was "soft" with tenderness in the right iliac fossa and hypochondrium.

As part of her initial work-up she had an abdominal x-ray requested "tro SBO".

What is the utility of a plain abdominal film in a patient with sepsis?
What abnormality does the image show?

Answer next week.

3 Comments

George

15/10/2017 03:38:24 pm

bHCG please...

Rebecca

20/12/2017 10:10:34 pm

I imagine the utility is poor, and that in sepsis the source is more likely to be haematogenous in nature.

However given her past history and clinical picture I would want to exclude tox causes of hyperthermia/HAGMA eg radioopaque drugs, body packing(unlikely), perforation (gas under diaphragm), obstruction (distension/fluid levels), suggestion of mesenteric ischemia from emboli (lack of gas pattern).

If that opacity in the bladder region is a fetus, then OMG! And I am assuming the pattern on the R quadrant is oxygen tubing, not an alien skeleton. And I do not think it is small bowel either.

So its either a baby or a surgical abdomen.

This appears to have paucity of gas pattern of the small bowel. Thus large bowel obstruction or ischemia is likely. There is gas in the rectum, and no obvious volvulus.

Titus

6/2/2018 02:09:00 pm

That is a beautifully gravid uterus. The head is inferior and you can see a leg crossing L4. A simple abdominal examination would have identified pregnancy in this woman, unless she was morbidly obese and would have also negated the need for a plain abdominal film.

Abdominal films are now obsolete in ED in the investigation of sepsis as a CT gives far more information. I'm struggling to think of a situation where a plain film trumps a CT in this setting, so we should stop wasting money and radiation.

Not what was expected ... but what was?

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