Image of the Day 18: Perforated Viscus

33 year old gentleman with no known medical illness, smoker, recreational drinker and no history of  NSAIDs abuse presented with sudden onset epigastric pain which is worsening, sharp in nature, radiating to the whole abdomen and persist even at rest. Pain score as being described by patient is 9/10. He denied history of nausea, vomiting, hematemesis, malaena or hemoptysis

Upon presentation, his vital signs are as follow; Respiratory rate 18/min, pulse rate 63 b.pm, SpO2 100% under room air, BP 106/63 and GCS is full.

On examination, patient is conscious and alert, in pain, pink, good hydrational and perfusion status. Abdomen examination reveals a board like rigidity with tenderness over the epigastric and right hypochondriac region. Examination of other system is unremarkable.

He was managed first with insertion of large bore IV line, IV tramadol 50 mg stat, IV metoclopromide 10 mg stat and IV ranitidine 50 mg stat and then sent for radiological evaluation.

Plain chest X ray, PA view Erect shows normal lung field and normal cardiac size and air under right diaphragm.

Upon further questioning, he still complaining of pain with score of 9/10. Subsequently, IV Fentanyl 50 mcg is given and he become more comfortable. Patient is then kept nil by mouth with IVD maintenance, Ryles tube insertion free flow with 4 hourly aspiration and vital sign monitoring and then sent for emergency exploratory laparotomy.

Intraoperatively, a perforation was found at the D1 section of duodenum. 

Disussion;

1) for the differential diagnosis of gas under diaphragm, you can refer this blog post

Chest X Ray: Air Under Diaphragm [link]

2) Giving an analgesia is not a contraindication in managing acute abdomen like the old traditional teaching. In fact, analgesia may aid in making diagnosis as patient is more calm and less anxiety. HOWEVER, peripheral blocking agent like NSAIDs should be avoided as it will masking the pain. based on experience, anti spasmodic agent like buscopan should also be avoided as it will mask the pain as well.