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Coffee-ground vomit and subdiaphragmatic air
  1. Ambrose Boles,
  2. Jack Pottle
  1. Ealing Hospital, Southall, London, UK
  1. Correspondence to Dr Jack Pottle, Ealing Hospital, Southall, London UB1 3HW, UK; jackpottle{at}hotmail.com

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Summary

A 90-year-old nursing home resident was admitted with confusion and reported ‘coffee-ground’ vomit. A chest radiograph was performed.

Coffee-ground vomit and subdiaphragmatic air

A 90-year-old female nursing home resident was found minimally responsive by her carers with a reported history of ‘coffee-ground’ vomit. She had a past medical history of Alzheimer's dementia and recent humeral fracture. Her only regular medication was lansoprazole 30 mg OD.

On arrival to the emergency department she was in circulatory shock with a blood pressure of 73/54 and pulse rate of 143 beats per minute. Respiratory rate was 44 and she was feverish at 38.2°C. Abdominal examination revealed guarding in the epigastrium and infrequent bowel sounds. There were coarse crepitations at the right lung base. Arterial blood gas on air revealed a pH of 7.35, pO2 of 6.28 and pCO2 of 2.57. Laboratory investigations showed haemoglobin of 13.0 g/dl, mild leukocytosis (10.9×109/l), impaired renal function (urea 12.6 mmol/l, creatinine 129 umol/l) and an elevated lactate (11 mmol/l). A portable chest radiograph (figure 1) and abdominal radiograph were performed in the resuscitation room.

Figure 1

Initial chest radiograph.

On initial inspection, the chest radiograph appears to show free air under the right hemidiaphragm. The history and clinical examination findings suggest a perforated viscus. If the patient was a fit candidate for surgery this would require surgical intervention and, in this case, a CT was requested to confirm the diagnosis of perforation.

In fact, the chest radiograph shows a pseudo-pneumoperioneum or Chilaiditi sign, first described by Demetrius Chilaiditi in 1910.1 Chilaiditi sign is the interposition of the bowel between the liver and the right hemidiaphragm, giving the appearance of free air on radiography. It has an incidence of 0.1–1%.1 This sign is clearly demonstrated on computerised tomography of the abdomen (figure 2). Chilaiditi syndrome is this anatomical variant in association with symptoms such as abdominal pain, vomiting or respiratory distress.2 ,3 The condition's pathogenesis is unknown, but frequently occurs in the presence of faecal impaction as in this case.1 ,2 The patient clinically improved with laxatives, which are the mainstay of treatment, and treatment for pneumonia.

Figure 2

Sagittal CT slice demonstrating interposition of the ascending colon between the liver and abdominal wall.

Chilaiditi sign may be diagnosed on radiography by looking for subtle haustral folds of bowel loops under the diaphragm, or by performing a left lateral decubitus abdominal radiograph.2

Acknowledgments

Many thanks to Dr Akkib Rafique for his input regarding the imaging in this manuscript.

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Footnotes

  • AB and JP contributed equally to this study.

  • Competing interests None declared.

  • Patient consent Verbal consent obtained and family willing to sign consent as legal guardians, due to patient's dementia. Awaiting return of consent form.

  • Ethics approval No intervention required—essentially a radiological case study. Verbal permission obtained and family willing to sign release of images.

  • Provenance and peer review Not commissioned; internally peer reviewed.

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