Unusual presentation of tension pneumoperitoneum during endoscopic submucosal dissection of early gastric tumor

Tension pneumoperitoneum is a well-known but rare complication of upper gastrointestinal endoscopy. It is defined as the massive accumulation of air in the peritoneal cavity, which results in a sudden increase in intraabdominal pressure resulting in hemodynamic or ventilatory compromise. The presentation varies from intense abdominal pain and tenderness to imminent collapse.


Cardiac tamponade in acute necrotising pancreatitis

Abstract

Objective: This case report highlights cardiac tamponade as a potentially significant complication of severe acute pancreatitis.

Settings: This patient was admitted to the Ng Teng Fong general hospital emergency department. He was subsequently admitted to the Intensive Care Unit (ICU) in the same hospital.

Patients: A 58-year-old male presented with severe acute gallstone pancreatitis with a Glasgow-Imrie criteria of 3. He was admitted for haemodynamic instability and acute respiratory distress syndrome (ARDS). The patient developed new-onset atrial fibrillation, persistent hypotension despite fluid resuscitation and increasing dependence on high inotropic support.

Investigations: A CT abdomen incidentally discovered an accumulation of pericardial fluid. Bedside echocardiography confirmed the presence of a large pericardial effusion consistent with cardiac tamponade. A CT scan revealed severe necrotising pancreatitis with a significant peripancreatic fluid collection.

Interventions: An emergency pericardiocentesis was performed and a pericardial drain was inserted. Eight hundreds ml of haemoserous pericardial fluid was drained over a period of 2 days. The patient’s haemodynamic status improved significantly after drainage of pericardial fluid.

Conclusion: Cardiac tamponade is one of the rare but clinically significant complications of severe acute pancreatitis and should be treated with a high index of suspicion in cases of acute pancreatitis with hypotension.


The case of the malpositioned feeding tube… while in plain sight

Patient WS is a 63-year-old male who presented to the Emergency Department (ED) with a chief complaint of progressive shortness of breath (SOB) over the past two weeks. Associated symptoms at time of presentation included acute bilateral lower extremity edema, orthopnea, and paroxysmal nocturnal dyspnea. His past medical history was significant for diabetes mellitus type II, hypertension, hypothyroidism, paroxysmal atrial fibrillation, paroxysmal ventricular fibrillation, non-ischemic cardiomyopathy (ejection fraction of 25%), severe mitral valve regurgitation, and newly diagnosed adenocarcinoma of the colon. The patient’s surgical history was significant for bi-ventricular ICD placement and gastric sleeve surgery.


Ureteral stents, sepsis and acute kidney injury: Iatrogenic imperfecta!

Case presentation

A 62-year-old woman with a past history of placement of bilateral ureteral “JJ” stents, presented to the hospital complaining of fever, chills, abdominal pain, oliguria and was found to be hypotensive. She was admitted to the intensive care unit (ICU), with the diagnosis of sepsis secondary to a urinary source. Her white blood cell count (WBC) was 21,200/mm3, blood urea nitrogen (BUN) 40 mg/dL, and serum creatinine 2.1 mg/dL. Her systolic blood pressure was 75 mmHg after administration of bolus of intravenous fluid (30 ml/Kg). She was then started on norepinephrine with improvement in her mean arterial blood pressure.


Mediastinal lipoma with vascular compression

Case description

A 56-year-old gentleman presented to the emergency department with shortness of breath and neck swelling of a couple of weeks duration. After a comprehensive physical examination and chest radiograph revealing an upper mediastinal abnormality, a computed tomography (CT) scan of the chest (Figures 1A and 1B) depicted a 8x7x5.7 cm mass with homogenous fat density and smooth margin, that was causing compression and anterior displacement of the superior vena cava and the left brachiocephalic vein. The patient underwent urgent surgery with removal of the tumor and postoperatively his symptoms had subsided.


Peripherally-inserted central catheters: Watch for retained wires!

An increasing number of patients are being admitted to critical care units with multiple chronic medical conditions. In some of these patients, intravenous access is a challenge. With a concern for indwelling catheter infections, peripherally inserted central catheters (PICC). These lines have been advocated due to their lower rate of complications and comfort to the patients. PICC are routinely inserted by physicians and trained nurses. Complications such as pneumothorax and infections are lower than in central venous lines and the incidence of retained guide wire is minimal and in some cases unrecognized.
We recently had one such case. An elderly man with sepsis required a PICC placement. A trained nurse attempted to place it when she recognized that the guidewire was missing, as the vessel dilator was being used. A chest radiograph confirmed that the guidewire remained in the patient’s chest cavity. Interventional radiology successfully retrieved the missing wire. Vigilance and frequent refresher courses are required to evaluate the competency among health care workers placing these catheters to help avoid complications.


Severe abdominal pain in a Jehovah’s Witness patient

A 76-year-old lady, with past medical history of hypertension, presented to the hospital with complains of severe right upper abdominal pain for 6 days prior to admission. A complete laboratory evaluation was non-revealing. An emergency computed tomography (CT) scan of the abdomen and pelvis revealed a hepatic artery aneurysm measuring 4 x 4 x 6 cm with unstable appearance (Figures 1,2,3). As the patient was a Jehovah’s Witness, and was not going to consent to receive any blood or blood product transfusion if needed, she was taken to the angiography suite emergently where a hepatic artery angiogram was performed. This was followed by embolization with an 8 mm coil, with successful reduction in the size of the aneurysm.

Severe abdominal pain in a Jehovah’s Witness patient


Angiokeratomas in the Intensive Care Unit

Case presentation
A 35-year-old Latin-American gentleman male with a history of Fabry’s disease presented for continuation of recombinant ceramide trihexosidase infusion therapy. Because of a prior allergic reaction, the patient was admitted to the intensive care unit during his infusion. He was first diagnosed in 2000, by genetic testing due to a strong male family history of the disease and had been receiving infusions every two weeks since 2007. Alphagalactosidase A level was 0.001%. He reported a history of anhidrosis, blurry vision, fatigue, headache, acroparesthesia, vertigo and diffuse angiokeratomas. These angiokeratomas (Figures 1 and 2), had a “bathing-trunk” distribution, but were also present in the inner labial mucosa as well as palms of the hands.

Angiokeratomas in the Intensive Care Unit


An unusual area for calciphylaxis in a critically ill patient

Case presentation
A 53-year-old gentleman with history of end-stage renal disease (ESRD) secondary to hypertension followed by a gunshot wound to the left flank region, presented to the hospital with complaints of fever, chills and severe pain in the groin area. In the emergency department he was found to have a blood pressure (BP) of 70/40 mmHg, heart rate (HR) of 130/min, respiratory rate (RR) 22/min and a temperature of 38 °C. The rest of his physical examination was significant for a toxic-appearing gentleman in mild distress. Lungs were clear to auscultation and percussion. His heart sounds were distant, but had normal characteristics and no murmurs were auscultated.

An unusual area for calciphylaxis in a critically ill patient


Severe dermatological presentation of graft vs host disease

A 67-year-old Caucasian female presented to the Surgical Intensive Care Unit (SICU) with an extensive dermatological manifestation of Graft vs. Host Disease (GVHD). She was transferred from the Bone Marrow Transplant (BMT) floor to the SICU for expertise in wound management and burn care. The patient had a past medical history of diffuse B-cell lymphoma for which she had undergone chemotherapy, achieving remission. Unfortunately, a year later she experienced recurrence of her cancer and underwent an autologous stem cell transplant. She subsequently developed an expanding skin rash, which upon biopsy revealed GVHD. Her disease progressed despite treatment with standard outpatient...
Severe dermatological presentation of graft vs host disease


An unusually large pleural cyst

A 93-year-old lady presented to the hospital complaining of 3 weeks of dysphagia, weight loss, dyspnea, and audible wheezing. Two days after admission, she was intubated and placed on assisted mechanical ventilation due to severe respiratory distress. A chest radiograph (CXR) showed a curvilinear, well circumscribed left superior paramediastinal opacity with suspected underlying mass (Figure 1, Panel A, arrow). Computed tomography (CT) of the chest with intravenous contrast revealed a large cystic mass measuring 9.3 x 6.4 x 4.6 cm, extending from the left supraclavicular region, immediately inferior to the thyroid gland, to the left hilar region (Figure 1, Panel B, arrow). The patient underwent open thoracotomy, where mass communication to the thoracic duct was noted, and complete surgical excision of a cyst filled with turbid and pale yellow fluid was achieved. Pathology report confirmed the diagnosis of a pleural cyst. The patient had no recurrence on CT and CXR after 4 weeks.
An unusually large pleural cyst


Painful skin lesions and bloody diarrhea

Pyoderma gangrenosum (PG) is a rare ulcerative lesion, commonly associated with an underlying systemic disease. The diagnosis of pyoderma gangrenosum can be challenging, and often requires a good history and exclusion of other ulcerative cutaneous disease. We present an impressive case of pyoderma gangrenosum in a young woman with bloody diarrhea.

Painful skin lesions and bloody diarrhea


A dermatologic presentation of pancreatitis

A 40-year-old adopted obese Caucasian male with a past medical history of type 2 diabetes, hypertension, and seizures presented to an Emergency Department with a one-day history of sharp epigastric pain accompanied by nausea and emesis. Dermatologic examination of his arms (Figure A) and legs (Figure B) was consistent with widespread cutaneous xanthomas secondary to hypertriglyceridemia. Venous and arterial (Figure C) blood samples appearing lipemic were obtained. His lipase level was 1,470 U/L and his triglyceride level was 13,563 mg/dL. CT imaging (Figures D and E) was consistent with necrotizing pancreatitis. He required admission to the Intensive Care Unit (ICU) for resuscitation, bowel rest, and supportive care. He underwent emergent plasmaphoresis with the goal of triglyceride reduction. (1) Hypertriglyceridemia is the third most common cause of pancreatitis (after alcohol abuse and gallstones) and is usually seen with triglyceride levels greater than 1000 mg/dL. (2) Patients may have a genetic predisposition such as type V hyperlipidemia and/or may have coexisting secondary causes of hypertriglyceridemia such as alcohol abuse, poorly controlled diabetes, obesity or rapid weight gain, hypothyroidism, uremia, nephritic syndrome, or third trimester pregnancy. (2) Management strategies include supportive care, early initiation of lipid lowering agents, tight glycemic control, plasma exchange, plasmaphoresis, and the use of heparin and insulin to stimulate lipoprotein lipase and chylomicron degradation (although data is limited for all of these strategies). (3) The patient’s prolonged ICU course was complicated by abdominal compartment syndrome, respiratory failure requiring tracheostomy, renal failure requiring renal replacement therapy (limiting the ability to use fibrates), and a partial pancreatic necrosectomy.

A dermatologic presentation of pancreatitis


Successful treatment of a massive pulmonary embolism using alteplase in a patient taking antipsychotic drugs

An increased risk of pulmonary embolism (PE) has been reported in female patients taking antipsychotic drugs. Furthermore, patients who take antipsychotic drugs are likely to present with malaise; therefore, the onset of PE is easily overlooked and often discovered by necropsy following PE-related sudden death. (1)

A 73-year-old woman was admitted to the emergency room because of severe shortness of breath and a rapid heartbeat, which had started 2 h earlier. Her medical history included severe depression that had left her bedridden for roughly 3 years. During that period, she frequently tired easily; however, her neighbors believed this to be a result of her depression and, therefore, were not concerned. On her arrival to the emergency room, the clinical examination confirmed hypotension (91/40 mmHg), tachycardia (109 bpm), and a peripheral oxygen saturation in room air of 80%. Examination of the cervix and chest revealed jugular venous distension. She had bilateral pitting edema of the lower extremities. On auscultation of the lungs, bilateral coarse crackles were audible.

An arterial blood gas test performed with the patient breathing room air showed evidence of type 1 respiratory failure (pH 7.49, pO2 52.7 mmHg, pCO2 21.0 mmHg). A scan obtained using portable, simple thoracic radiography revealed patchy shadowing (Figure 1). At this point, we suspected a massive pulmonary embolism, and a computed tomography (CT) pulmonary angiogram revealed extensive bilateral pulmonary embolisms (Figure 2). The patient was immediately thrombolysed with alteplase, which commenced 3 h after symptom onset. The dose was calculated for her body weight of 60 kg, resulting in 4 mg given as an intravenous bolus, followed by an intravenous infusion of 36 mg administered over a 1-h period. Eight hours later, following the thrombolytic treatment, the patient improved and was hemodynamically stable (blood pressure 130/68 mmHg, heart rate 90 bpm) with a peripheral oxygen saturation in room air of 93%. Therefore, the patient was successfully thrombolysed without any complications (Figures 3a and 3b).

Several mechanisms have been proposed for the thrombotic complications associated with the platelet aggregation induced by antipsychotic drugs including the presence of anticardiolipin antibodies and type 2A serotonin receptors. (2,3) However, anticardiolipin antibodies were not detected in this patient, and she had not taken medication related to type 2A serotonin receptors. We were able to diagnose the pulmonary infarction by recognizing the presence of abnormal vital signs that we could not explain. Therefore, the proper evaluation of vital signs is important even in patients with considerable malaise.

Successful treatment of a massive pulmonary embolism using alteplase in a patient taking antipsychotic drugs


Gastromegaly as the cause of unexplained chest pain

A 61-year-old gentleman with past medical history of hypertension, hyperlipidemia, gastroesophageal reflux status post hiatal hernia repair in 1973, and recurrent diverticulitis was admitted to the intensive care unit (ICU) after undergoing elective laparoscopic recto-sigmoid hemicolectomy and colostomy formation. His immediate postoperative course was complicated by syncope while getting out of bed to ambulate. The patient regained consciousness within minutes and noted severe substernal chest pressure and dyspnea at rest. Physical examination revealed a blood pressure of 70/40 torr, heart rate 130/min and respiratory rate 28/min. Chest examination was unremarkable. Mild abdominal distension was noted without discomfort to palpation, and diffuse tympani on percussion. An emergent electrocardiogram was unremarkable. The patient received intravenous fluids and vasopressors. Laboratory testing revealed acute blood loss anemia with drop in baseline hemoglobin of four grams per deciliter. Following stabilization while awaiting blood transfusion, a chest X-ray was performed demonstrat­ing severe gastromegaly, which was then confirmed by abdominal X-ray (Figures 1 and 2). Subsequent abdominal and pelvic computed tomography (CT) with contrast to assess for obstruction, confirmed the pres­ence of gastromegaly without obstruction, and left lower quadrant hematoma without active bleeding (Figure 3). A nasogastric tube on continuous suction was inserted with subsequent resolution of the patient’s symptoms as well as the objective findings of hypotension, tachy­cardia, and tachypnea. A repeat radiograph revealed decompression of the patient’s stomach (Figure 4). Pressor support was weaned, and after completion of the patient’s blood transfusion, stopped. The patient had no further complications post-operatively and discharged home on post-operative day 2.

Gastromegaly as the cause of unexplained chest pain