{"id":238,"date":"2018-06-27T03:49:35","date_gmt":"2018-06-27T03:49:35","guid":{"rendered":"https:\/\/blogs.bmj.com\/fg\/?p=238"},"modified":"2018-09-10T11:35:40","modified_gmt":"2018-09-10T11:35:40","slug":"unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain","status":"publish","type":"post","link":"https:\/\/blogs.bmj.com\/fg\/2018\/06\/27\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\/","title":{"rendered":"Unusual findings in a Patient Presenting with Right Upper Quadrant Pain"},"content":{"rendered":"<p>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\u2019s 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.<\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>Question<\/p>\n<p>Reviewing the images what is the cause of this patient\u2019s subcutaneous emphysema?<\/p>\n<p>&nbsp;<\/p>\n<p><a href=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide1.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-240\" src=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide1-300x169.png\" alt=\"\" width=\"300\" height=\"169\" srcset=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide1-300x169.png 300w, https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide1-640x360.png 640w, https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide1.png 720w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p><a href=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide2.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-241\" src=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide2-300x169.png\" alt=\"\" width=\"300\" height=\"169\" srcset=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide2-300x169.png 300w, https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide2-640x360.png 640w, https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide2.png 720w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p><a href=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide3.png\"><img loading=\"lazy\" decoding=\"async\" class=\"alignnone size-medium wp-image-242\" src=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide3-300x169.png\" alt=\"\" width=\"300\" height=\"169\" srcset=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide3-300x169.png 300w, https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide3-640x360.png 640w, https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide3.png 720w\" sizes=\"auto, (max-width: 300px) 100vw, 300px\" \/><\/a><\/p>\n<p>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.<\/p>\n<p>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.<\/p>\n<p>Figure 3: Photograph of patient\u2019s abdomen 4 months from initial presentation showing large right sided swelling.<\/p>\n<p>&nbsp;<\/p>\n<p class=\"BodyA\" style=\"text-align: left\"><span lang=\"EN-US\">Corresponding Author<\/span><\/p>\n<p class=\"Default\" style=\"text-align: left\"><span lang=\"EN-US\">Dr Noor Jawad MBBS BSc PhD MRCP (UK) MRCP (Gastro)<\/span><\/p>\n<p class=\"Default\" style=\"text-align: left\"><span lang=\"EN-US\">Consultant Gastroenterologist and Honorary Senior Lecturer at the Blizard Institute, Centre for Genomics and Child Health<\/span><\/p>\n<p class=\"Default\" style=\"text-align: left\"><span lang=\"EN-US\">Bart&#8217;s and The London School of Medicine and Dentistry<\/span><\/p>\n<p class=\"Default\" style=\"text-align: left\"><span lang=\"EN-US\">Co-Author <\/span><\/p>\n<p class=\"Default\" style=\"text-align: left\"><span lang=\"EN-US\">Dr Harry Coleman MbChB BSc<\/span><\/p>\n<p class=\"Default\" style=\"text-align: left\"><span lang=\"EN-US\">CMT Department of Gastroenterology<\/span><\/p>\n<p class=\"Default\" style=\"text-align: left\"><span lang=\"EN-US\">Newham University Hospital<\/span><\/p>\n<p class=\"Default\" style=\"text-align: left\"><span class=\"Hyperlink0\"><span lang=\"EN-US\"><a href=\"mailto:harry.Coleman@bartshealth.nhs.uk\">harry.Coleman@bartshealth.nhs.uk<\/a><\/span><\/span><u><\/u><\/p>\n<p><!--TrendMD v2.4.8--><\/p>\n","protected":false},"excerpt":{"rendered":"<p>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\u2019s history of productive cough and shortness of breath. He had a [&#8230;]<\/p>\n<p><a class=\"btn btn-secondary understrap-read-more-link\" href=\"https:\/\/blogs.bmj.com\/fg\/2018\/06\/27\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\/\">Read More&#8230;<\/a><\/p>\n","protected":false},"author":308,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[10257],"tags":[],"class_list":["post-238","post","type-post","status-publish","format-standard","hentry","category-fgcaseofthemonth"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v27.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Unusual findings in a Patient Presenting with Right Upper Quadrant Pain - Frontline Gastroenterology Blog<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/blogs.bmj.com\/fg\/2018\/06\/27\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Unusual findings in a Patient Presenting with Right Upper Quadrant Pain - Frontline Gastroenterology Blog\" \/>\n<meta property=\"og:description\" content=\"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\u2019s history of productive cough and shortness of breath. He had a [...]Read More...\" \/>\n<meta property=\"og:url\" content=\"https:\/\/blogs.bmj.com\/fg\/2018\/06\/27\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\/\" \/>\n<meta property=\"og:site_name\" content=\"Frontline Gastroenterology Blog\" \/>\n<meta property=\"article:published_time\" content=\"2018-06-27T03:49:35+00:00\" \/>\n<meta property=\"article:modified_time\" content=\"2018-09-10T11:35:40+00:00\" \/>\n<meta property=\"og:image\" content=\"https:\/\/blogs.bmj.com\/fg\/files\/2018\/06\/Slide1-300x169.png\" \/>\n<meta name=\"twitter:card\" content=\"summary_large_image\" \/>\n<meta name=\"twitter:label1\" content=\"Written by\" \/>\n\t<meta name=\"twitter:data1\" content=\"\" \/>\n\t<meta name=\"twitter:label2\" content=\"Est. reading time\" \/>\n\t<meta name=\"twitter:data2\" content=\"2 minutes\" \/>\n<script type=\"application\/ld+json\" class=\"yoast-schema-graph\">{\"@context\":\"https:\\\/\\\/schema.org\",\"@graph\":[{\"@type\":\"Article\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/2018\\\/06\\\/27\\\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\\\/#article\",\"isPartOf\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/2018\\\/06\\\/27\\\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\\\/\"},\"author\":{\"name\":\"\",\"@id\":\"\"},\"headline\":\"Unusual findings in a Patient Presenting with Right Upper Quadrant Pain\",\"datePublished\":\"2018-06-27T03:49:35+00:00\",\"dateModified\":\"2018-09-10T11:35:40+00:00\",\"mainEntityOfPage\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/2018\\\/06\\\/27\\\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\\\/\"},\"wordCount\":347,\"commentCount\":0,\"publisher\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/#organization\"},\"image\":{\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/2018\\\/06\\\/27\\\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\\\/#primaryimage\"},\"thumbnailUrl\":\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/files\\\/2018\\\/06\\\/Slide1-300x169.png\",\"articleSection\":[\"#FGCaseofthemonth\"],\"inLanguage\":\"en-US\",\"potentialAction\":[{\"@type\":\"CommentAction\",\"name\":\"Comment\",\"target\":[\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/2018\\\/06\\\/27\\\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\\\/#respond\"]}]},{\"@type\":\"WebPage\",\"@id\":\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/2018\\\/06\\\/27\\\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\\\/\",\"url\":\"https:\\\/\\\/blogs.bmj.com\\\/fg\\\/2018\\\/06\\\/27\\\/unusual-findings-in-a-patient-presenting-with-right-upper-quadrant-pain\\\/\",\"name\":\"Unusual findings in a Patient Presenting with Right Upper Quadrant Pain - 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