A 69 year old gentleman presented to the ED with a 1 day history of right upper quadrant abdominal pain. He described the pain as cramping in nature radiating to his lower abdomen. He denied any history of trauma but did report a week’s history of productive cough and shortness of breath. He had a background history of hypertension and hyperlipidaemia. Of note, on examination, the patient had extensive bruising on the right chest and lateral abdominal wall.
The patient was initially referred to the general surgeons although not accepted as CT abdomen/pelvis showed no acute surgical pathology. The patient went on to be diagnosed and treated for community acquired pneumonia with a CTPA showing no pulmonary embolus but collapse and consolidation of the right middle lobe.
5 days into admission the on-call medical team were asked to review the patient who had a persistent tachycardia and three episodes of vomiting. On examination the patient had extensive subcutaneous emphysema (SE) which tracked throughout the back, precordium and neck. The bruising as seen before had extended. Other than a heart rate of 120 the patient was haemodynamically stable. There had been no history of drain insertion.
Question
Reviewing the images what is the cause of this patient’s subcutaneous emphysema?
Figure 1: CT C/A/P showing herniation through the upper aspect of the right lateral abdominal wall passing though the abnormally widened right seventh intercostal space.
Figure 2: CT C/A/P showing the hernia containing a large amount of fat; small intestinal loops; the hepatic flexure of the colon and the fundus of the gall bladder.
Figure 3: Photograph of patient’s abdomen 4 months from initial presentation showing large right sided swelling.
Corresponding Author
Dr Noor Jawad MBBS BSc PhD MRCP (UK) MRCP (Gastro)
Consultant Gastroenterologist and Honorary Senior Lecturer at the Blizard Institute, Centre for Genomics and Child Health
Bart’s and The London School of Medicine and Dentistry
Co-Author
Dr Harry Coleman MbChB BSc
CMT Department of Gastroenterology
Newham University Hospital
harry.Coleman@bartshealth.nhs.uk