Presentation
Respiratory failure requiring intubation and mechanical ventilation.
Patient Data
Almost complete opacification of the right hemithorax. The appearance suggests areas of parenchymal consolidation and pleural effusion with underlying atelectatic changes.
Large Mass like lesion replacing most of the right upper lobe extending to the hilum and chest wall obstructing right main bronchus. Pathological mediastinal lymphadenopathy. Collapse consolidation right middle lobe. Moderate right effusion. Minimal leftward mediastinal displacement. Scattered spiculated nodular opacities left upper and lower lobes.
The patient had respiratory deterioration despite increasing pressures on the ventilator to maintain oxygenation. The endotracheal tube was therefore repositioned, and a chest x-ray was ordered to 'evaluate for placement'.
CXR after endotracheal tube re-positioning
Endotracheal tube has been slightly retracted, now terminating approximately 4 cm above the carina. Enteric catheter courses below the diaphragm. Right internal jugular central venous catheter terminates in a stable position, with tip projecting over the cavoatrial junction. A new left internal jugular central venous catheter is seen, with tip projecting over the proximal brachiocephalic vein. There has been interval development of a large right pneumothorax with air under both diaphragms, compatible with pneumoperitoneum. Diffuse consolidation is seen within the collapsed right lung. The left lung is clear.
The pneumothorax is thought to have resulted from some combination abscess rupture, re-intubation, bagging and high pressures delivered from the ventilator – a chest tube was placed in the apex of the right lung. An emergency surgery consult was made and the patient was taken for exploratory laparotomy for a gastrointestinal source of pneumoperitoneum. The surgery was non-diagnostic revealing no rupture of the GI tract. She tolerated the surgery without immediate complication but continued to be ventilator dependent for months requiring tracheostomy for slow vent weaning. The chest tube was removed on Day 90 after hospitalization.
Endotracheal is again seen, stable in position. Enteric catheter courses below the diaphragm. Right internal jugular central venous catheter terminates in a stable position, with tip projecting over the cavo-atrial junction. Left internal jugular central venous catheter tip projects over the distal SVC. There has been interval placement of a chest tube, terminating in the right apex. There has been interval re-expansion of the right lung, with residual right apical pneumothorax. There is persistent bilateral pneumoperitoneum. Diffuse consolidation is again seen within the right lung. The left lung is clear.
Enteric catheter tip projects over the left upper quadrant. There is extensive pneumoperitoneum with centralization of bowel loops secondary to mass effect. Surgical clips project over the lower pelvis consistent with hysterectomy. Temperature probe projects over the mid-lower pelvis. No acute osseous abnormalities are identified.
Case Discussion
85-95% of pneumoperitoneum is associated with gastrointestinal perforation, but in the absence of peritoneal signs, fever, or leukocytosis, a perforated bowel becomes less likely. If there is another evident cause for free air under the diaphragm in addition to a lack of clinical signs and symptoms associated with perforated bowel, then surgery may not be necessary and may expose the patient to unnecessary risk. A radiologist can assist the clinical counterparts by identifying potential alternative sources of pneumoperitoneum relevant to the patient such as recent pneumothorax with chest tube placement identified by chest x-ray in this patient.
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