Presentation
Known metastatic head-neck squamous cell carcinoma. Unable to swallow, experiencing shortness of breath. Normal WBC count. Distended abdomen, no abdominal pain.
Patient Data
Supine chest x-ray showed no evident pulmonary cause of shortness of breath.
A large amount of gas is below the diaphragm. Due to the supine position, it suggests:
colon interposititum and ileus
a large amount of free abdominal air
Large amount of dense ascites in the lesser pelvis and dense ascites in the epigastrial region.
Compression of the epigastric region revealed free abdominal air:
the liver is not visible
reverberation artefacts, resembling lung A-lines
Due to impaired renal function, a non-contrast CT was performed. The CT examination confirmed large free abdominal gas and ascites. The large amount of air and free fluid suggests gastric perforation.
Case Discussion
Supine chest or abdominal X-ray has limited sensitivity and specificity in detecting free abdominal air. The large amount of free air and dense ascites was easily visible with ultrasound. CT confirmed both of them but was unable to detect the position of the perforation. Due to a large amount of pneumoperitoneum and ascites, gastric perforation was suspected. An acute operation was performed, confirming gastric perforation.
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