Feng Yan-Mei, Wan Dong, Guo Rui
Department of Respiratory and Critical Care Medicine Department of Critical Care Medicine, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China.
Medicine (Baltimore). 2018 May;97(20):e10757. doi: 10.1097/MD.0000000000010757.
Critical care ultrasound identifies the signs of free intraperitoneal air and echogenic free fluid always indicates hollow viscus perforation (HVP) and needs immediate surgical interventions. However, in rare cases, these classic signs may also mislead proper clinical decisions. We report perforated viscus associated large peritoneal effusion with initial critical care ultrasound findings, whereas computed tomography (CT) examination confirmed a giant stomach due to superior mesenteric artery syndrome (SMAS).
A 70-year-old man was admitted to our emergency department with a complaint of recurrent vomiting with coffee ground emesis for 15 hours and worsen with hypotension for 6 hours. During gastric tube placement, the sudden cardiac arrest occurred. With 22 minutes resuscitation, sinus rhythm was restored.
Quick ultrasound screen showed large echogenic fluid distributed in the whole abdomen. Diagnostic paracentesis collected "unclotted blood" and combined with a past history of duodenal ulcer, HVP was highly suspected. However, surgical intervention was not performed immediately as unstable vital signs and unfavorable coma states. After adequate resuscitation in intensive care unit, the patient was transferred to perform enhanced CT. Surprisingly, there was no evidence of HVP. Instead, CT showed a giant stomach possibly explained by SMAS.
Continuous gastric decompression was performed and 3100 mL coffee ground content was drainage within 24 hours of admission.
Abdominal distension was significantly relieved with improved vital signs. However, as the poor neurological outcome, family members abandon further treatment, and the patient died.
SMAS is a rare disorder, characterized by small bowel obstruction and severe gastric distension. Nasogastric tube insertion should be aware to protect airway against aspiration. Caution should be utilized to avoid over interpretation of ultrasonography findings on this condition.
重症超声可识别腹腔内游离气体的征象，而强回声游离液体总是提示中空脏器穿孔（HVP），需要立即进行手术干预。然而，在极少数情况下，这些典型征象也可能误导正确的临床决策。我们报告了一例伴有大量腹腔积液的穿孔脏器病例，其最初的重症超声检查结果显示如此，而计算机断层扫描（CT）检查证实是由于肠系膜上动脉综合征（SMAS）导致的巨大胃。
一名70岁男性因反复呕吐伴咖啡渣样呕吐物15小时入院，6小时来因低血压病情加重。在放置胃管过程中，突然发生心脏骤停。经过22分钟的复苏，恢复了窦性心律。
快速超声检查显示全腹有大量强回声液体。诊断性腹腔穿刺抽出“未凝血”，结合既往十二指肠溃疡病史，高度怀疑HVP。然而，由于生命体征不稳定和昏迷状态不佳，未立即进行手术干预.在重症监护病房进行充分复苏后，患者转去做增强CT。令人惊讶的是，没有HVP的证据。相反，CT显示一个巨大胃，可能由SMAS解释。
持续进行胃肠减压.入院24小时内引流出31** **00毫升咖啡渣样内容物。
腹胀明显缓解，生命体征改善。然而.由于神经功能预后差，家属放弃进一步治疗，患者死亡。
SMAS是一种罕见疾病，其特征为小肠梗阻和严重胃扩张。插入鼻胃管时应注意保护气道防止误吸。对于这种情况，应谨慎避免对超声检查结果过度解读。
