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Free Air &... Coconuts (?)

Last week a 32yo male presented to our clinic with generalized abdominal pain. He was tachycardic with a soft blood pressure. On physical exam, he had a distended tense abdomen with diffuse tenderness to palpation. Labs were notable for an elevated lactate.

He was placed on a monitor. Peripheral IV was started. He was made NPO. Intravenous fluids were initiated as well as broad spectrum antibiotics. His symptoms were addressed with IV analgesia and IV anti-emetics.

Point-of-care abdominal ultrasound was performed. Despite being a fairly thin patient, it was difficult for me to visualize his intra-abdominal organs due to diffuse gas. Video clip below.

Gas inside the intestines, while perhaps uncomfortable, is not typically dangerous (with rare exceptions). Conversely, free air or gas inside the peritoneal cavity, but not contained within bowel is not normal and is of significant concern.

A few of the ultrasound findings that can raise concern for pneumoperitoneum are described here:

"The interface between the anterior abdominal wall and the adjacent peritoneal fluid results in a thin echogenic line on baseline ultrasound imaging. The abnormal presence of air in the abdomen scatters the ultrasound waves at the interface of soft tissue and air. This produces a high-amplitude linear echo known as the enhanced peritoneal stripe line which has been reliably established by various studies and a review article.

The focal enhancement of the peritoneal stripe may be associated with posterior reflection artefacts. These reflection artefacts are a result of the appearance of air on ultrasound as an echogenic, reflective interface that obscures underlying anatomy. Long path reverberation artefacts are seen as horizontal stripes created when the ultrasound waves reflect between air and the overlying fascial plane." *

Examples of the described findings on our patient's scan.

The combination of the patient's history, physical exam findings, and ultrasound imaging was very suggestive of our patient having an acute abdomen due to perforated hollow viscus. He needed a surgeon... ASAP.

We loaded him into our ambulance and transferred him emergently to the nearest government hospital with on-call surgical services. He went to the OR and subsequently the ICU. He is now out of the ICU and recovering well.

Great! But where do coconuts come into play? Glad you asked.

Our patient was non-verbal. Per family (you can't make this up), he spoke normally up until approximately 8 years ago. Then... a coconut fell on his head (?!). He has not spoken since.

His inability to speak certainly may have played a significant role in the progression of his acute intra-abdominal process. It is not unlikely that he was unable to convey to his family the degree of his abdominal discomfort in the days prior to presentation. This breakdown in communication could certainly explain a delay in seeking care and this delay may have led to bowel perforation.

Regardless of the factors that may or may not have contributed to our patient's presentation with an acute abdomen and evidence of pneumoperitoneum, we are pleased to have played a small role in his receiving timely and appropriate care.

And... we will likely exercise a bit more caution when strolling under coconut trees.

*Khor M, Cutten J, Lim J, Weerakkody Y. Sonographic detection of pneumoperitoneum. BJR Case Rep. 2017 May 4;3(4):20160146. doi: 10.1259/bjrcr.20160146. PMID: 30363233; PMCID: PMC6159171.

Top Photo by Gerson Repreza on Unsplash


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