Adhesion Colic: Don’t Forget the Erect CXR

This patient is a 45 years old lady with history of hysterectomy five years ago due to uterine fibroid and two history of admission due to sub acute IO secondary to adhesion colic which relief by conservative treatment. She presented to health care provider for three times within 24 hours due to severe abdominal pain.

The pain being described as colicky, starting at the upper abdomen and radiate to the whole abdomen, initially relieve temporarily with IV analgesia given by the healthcare provider. The pain score is 7-8/10, and associated with nausea and vomiting, anorexia and feeling un well.

The abdominal radiograph shows dilated small bowel and the CXR erect shows air under the right diaphragm.

Discussion

Two modalities of radiological investigation in emergency department for evaluating acute abdomen are plain radiograph and CT scan.

Selection of modality depends on your working diagnosis. The current practice to use plain radiograph as screening modality should be discouraged except under certain circumstances.

Abdominal and CXR Erect is particularly helpful in evaluating acute abdomen due to free air secondary to small bowel obstruction, perforated peptic ulcer disease and foreign body. In my practice, I still prefer to take AXR as an evidence of diagnosing constipation.

Meanwhile, CT abdomen has higher sensitivity for bowel obstruction, urolithiasis, appendicitis, pancreatitis, pyelonephritis and diverticulitis (James H Street & Xzabia Caliste)

Adhesion colic can present with varying degree of severity. Most often, it is the movement of bowel together with the joined bowel by adhesion that causing pain. However, the presence of vomiting, constipation warrants and AXR to look for mechanical bowel obstruction. If Patient presented with a very tender abdomen and patient look un well, you should take the erect CXR as well since minority of them may actually develop perforated viscous or leakage of air.

Abdominal X Ray: Megacolon

This the radiological image of 2 years old kid who presented with progressive constipation and abdominal distension for 5 months.

Imaging of abdomen shows huge dilatation of ascending, transverse and descending colon.

A Diagnosis of Megacolon secndary to Hirschprung disease was made

Quiz: Acute Abdomen with UGIB

This 33 years old lady presented with vomiting out blood, passing out blackish discoloration of the stool and abdominal pain.

This is her erect chest X ray film. Explained your finding and possible diagnosis

Answer

The chest X ray erect film shows gas under the left diaphragm and the diagnosis is perforated gastric ulcer.

Note: laparotomy was done in this patient and noted finding of large PGU but still managed to be repaired with Graham's patches

For further discussion on this topic, click

Image of the Day 18: Perforated Viscus [Link]

Chest X Ray: Air Under Diaphragm [Link]

 

Right Lung Fibrosis with Chronic Lung Disease

This is a chest x ray belongs to a 50 years old gentleman who presented with worsening of cough for 2 days duration associated with yellowish sputum production. On examination, he is tachypnoeic with respiratory distress, tachycardic and SPO2 under room air 80%.

Examination of the Respiratory systems reveals clubbing, peripheral cyanosis, no Horner syndrome. Chest examination shows pectus carinatum with reduce chest movement at the right side. The trachea is deviated to right side. Air entry reduced on the right side. Soft crackles at the right upper zone and coarse crackles over the right lower zone. Percussion note is resonance over the right lung zone.

On further questioning, he was previously treated for pulmonary tuberculosis and completed the treatment regime and being well except for on and off shortness of breath.

The Chest X ray shows 1) Hyper inflated lung, 2) Trachea deviated to right site, 3) heterogeneous opacities of the right lung field, 4)loss of cardiac silhouette, 5)obliteration of right costophrenic angle, 6) ? Bullae at right upper-middle lateral lung region.

Based on the history and clinical findings, an impression of chronic lung disease with lower respiratory tract infection, TRO PTB reactivation was made.

Left TMJ Dislocation

This skull x ray belongs to a 28 year old lady who presented with second episodes of left temporomandibular joint dislocation. The unfortunate event occurs when she was yawning.

A successful reduction of TMJ dislocation was done under analgesia with IV Fentanyl 75 mg and patient was discharged with follow up under dental surgery

The video uploaded from the YouTube shows exactly how we reduce the dislocation.