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Is it possible to differentiate between pseudopneumoperitoneum and similar pathologies ultrasonographically?

View Article: PubMed Central - PubMed

ABSTRACT

Aim: The goal of the work was comparing gas ultrasound images below the right diaphragm in two groups: in people with intestinal interposition below the diaphragm and ones with pneumoperitoneum and extracting the traits differentiating these two conditions.

Material and methods: Retrospectively, the documentation of 22 patients with intestinal interposition below the diaphragm (group 1) was utilized. Clinical material was used for comparison, previously published, composed of 15 cases of pneumoperitoneum following laparotomy and of 14 cases following that symptom as a result of ulcer perforation – group 2 (in total n = 29). Moreover, the distance in millimeters of the gas surface reflecting ultrasounds from the parietal peritoneum was measured, the smoothness of the surface, parietal peritoneum enhancement at the place of gas adherence, gas continuity below the diaphragm with gas in the intestine located below the liver.

Results: Direct adherence of the gas surface to the diaphragm was observed in 100% of the cases of emphysema, but in no cases of intestinal interposition. Yet, in the group of patients with colonic interposition (n = 21) there was always a small gap (2–3 mm) and the gas surface among those patients in 100% of the cases was uneven.

Conclusions: In differentiation between pneumoperitoneum and liver-diaphragm interposition of the intestine one should take into account – apart from gas movement below the diaphragm at body position changing – the presence of protrusion and section enhancement of the diaphragmatic peritoneum as well as the distance of the gas from the diaphragm, the smoothness of its surface and the continuity with the intestine below the liver. Interpositions of small diaphragm-liver penetration may subside in erect position.

No MeSH data available.


Colon over the right lobe of the liver (L) visible on the right cross-section. Arrows indicate the wavy outline of the gas in the intestine
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f0001: Colon over the right lobe of the liver (L) visible on the right cross-section. Arrows indicate the wavy outline of the gas in the intestine

Mentions: In group 1, hepatic flexure over the right hepatic lobe was diagnosed in 15 cases (Fig. 1), colon over the whole liver in 2 cases (Fig. 2), colon over segments IV, III and II of the liver in 2 cases (Fig. 3), colon over the left hepatic lobe in 2 people (Fig. 4) and small intestine over the right hepatic lobe in the patient following endoscopy of the upper section of the gastrointestinal tract (Fig. 5). The colon reached into the subdiaphragmatic area from 3 cm to 8 cm (from the liver border), never crossing the apex of the phrenic dome. Gap of the gas surface from the parietal peritoneum ranged within 2–3 mm (on average 2.7 mm). Only in the case of small intestine relocation below the diaphragm, the gap reached approx. 1 mm. Among 12 people examined inerect position, in 4 with a slight intestinal transposition, remission was observed in that position (Fig. 6); among the remaining patients, the intestine still remained under the diaphragm (Fig. 7). Other data concerning intestinal interposition under the diaphragm are included in Tab. 1. In group 2, in all the patients, a changing location of the gas in the peritoneal cavity was observed as well as sectional parietal peritoneum enhancement at the place of direct contact with gas. In this group, no gap between the diaphragm and the permanently smooth surface of the gas was observed (Fig. 8). Depending on the amount of gas collected, there were various artifacts: bubbles caused an artifact close to the comet tail, while its greater amount caused the release of artifact of multiple reflections or closed curtain. The greatest diagnostic difficulty was present in the case of a patient with small intestine relocation below the diaphragm right after gastroscopy. The gas surface was smooth in this case and almost directly adjoining the diaphragm (Fig. 5). On the other hand, the basic symptom against pneumoperitoneum was the constant location of the gas below the diaphragm despite the attempts to change the position of the patient. Finally, the diagnosis was determined after X-rays made of the abdominal cavity, where – in the place colon below the diaphragm, there was a small intestine loop, and on the basis of control ultrasound examination after 2 hours from pain in the abdomen remission. This examination showed no presence of the previously observed symptom. An extraordinary discovery was finding an impressed right colonic flexure into the hepatorenal recess (Fig. 9).


Is it possible to differentiate between pseudopneumoperitoneum and similar pathologies ultrasonographically?
Colon over the right lobe of the liver (L) visible on the right cross-section. Arrows indicate the wavy outline of the gas in the intestine
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC5392551&req=5

f0001: Colon over the right lobe of the liver (L) visible on the right cross-section. Arrows indicate the wavy outline of the gas in the intestine
Mentions: In group 1, hepatic flexure over the right hepatic lobe was diagnosed in 15 cases (Fig. 1), colon over the whole liver in 2 cases (Fig. 2), colon over segments IV, III and II of the liver in 2 cases (Fig. 3), colon over the left hepatic lobe in 2 people (Fig. 4) and small intestine over the right hepatic lobe in the patient following endoscopy of the upper section of the gastrointestinal tract (Fig. 5). The colon reached into the subdiaphragmatic area from 3 cm to 8 cm (from the liver border), never crossing the apex of the phrenic dome. Gap of the gas surface from the parietal peritoneum ranged within 2–3 mm (on average 2.7 mm). Only in the case of small intestine relocation below the diaphragm, the gap reached approx. 1 mm. Among 12 people examined inerect position, in 4 with a slight intestinal transposition, remission was observed in that position (Fig. 6); among the remaining patients, the intestine still remained under the diaphragm (Fig. 7). Other data concerning intestinal interposition under the diaphragm are included in Tab. 1. In group 2, in all the patients, a changing location of the gas in the peritoneal cavity was observed as well as sectional parietal peritoneum enhancement at the place of direct contact with gas. In this group, no gap between the diaphragm and the permanently smooth surface of the gas was observed (Fig. 8). Depending on the amount of gas collected, there were various artifacts: bubbles caused an artifact close to the comet tail, while its greater amount caused the release of artifact of multiple reflections or closed curtain. The greatest diagnostic difficulty was present in the case of a patient with small intestine relocation below the diaphragm right after gastroscopy. The gas surface was smooth in this case and almost directly adjoining the diaphragm (Fig. 5). On the other hand, the basic symptom against pneumoperitoneum was the constant location of the gas below the diaphragm despite the attempts to change the position of the patient. Finally, the diagnosis was determined after X-rays made of the abdominal cavity, where – in the place colon below the diaphragm, there was a small intestine loop, and on the basis of control ultrasound examination after 2 hours from pain in the abdomen remission. This examination showed no presence of the previously observed symptom. An extraordinary discovery was finding an impressed right colonic flexure into the hepatorenal recess (Fig. 9).

View Article: PubMed Central - PubMed

ABSTRACT

Aim: The goal of the work was comparing gas ultrasound images below the right diaphragm in two groups: in people with intestinal interposition below the diaphragm and ones with pneumoperitoneum and extracting the traits differentiating these two conditions.

Material and methods: Retrospectively, the documentation of 22 patients with intestinal interposition below the diaphragm (group 1) was utilized. Clinical material was used for comparison, previously published, composed of 15 cases of pneumoperitoneum following laparotomy and of 14 cases following that symptom as a result of ulcer perforation – group 2 (in total n = 29). Moreover, the distance in millimeters of the gas surface reflecting ultrasounds from the parietal peritoneum was measured, the smoothness of the surface, parietal peritoneum enhancement at the place of gas adherence, gas continuity below the diaphragm with gas in the intestine located below the liver.

Results: Direct adherence of the gas surface to the diaphragm was observed in 100% of the cases of emphysema, but in no cases of intestinal interposition. Yet, in the group of patients with colonic interposition (n = 21) there was always a small gap (2–3 mm) and the gas surface among those patients in 100% of the cases was uneven.

Conclusions: In differentiation between pneumoperitoneum and liver-diaphragm interposition of the intestine one should take into account – apart from gas movement below the diaphragm at body position changing – the presence of protrusion and section enhancement of the diaphragmatic peritoneum as well as the distance of the gas from the diaphragm, the smoothness of its surface and the continuity with the intestine below the liver. Interpositions of small diaphragm-liver penetration may subside in erect position.

No MeSH data available.