Caceres’ Corner Case 116 (Update: Solution)


Dear Friends,

Since summer is coming (Game of Thrones revisited), I am presenting an easy case today. Images belong to an asymptomatic 67-year-old female with scleroderma. She had a lung transplant last year and a gastrostomy one month ago.

What do you see?

Check the images below, leave your thoughts in the comments section and come back on Friday for the answer.

lateral chest

PA chest

Click here for the answer to case #116

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    May 2015
    DISCUSSION 22 Comments

    22 Responses to : Caceres’ Corner Case 116 (Update: Solution)

    1. Kerrya says:

      Right pneumoperithoneum. Elevated right hemidiphragm.

    2. genchi bari italia says:

      …il caso è facile, anche se il mitico professore non dice sempre tutta la verità !Il trapianto di polmone non c’entra nulla….c’è stata una PEG, per la patologia esofagea e quest’ultima ha avuto una complicanza…si è sfilato il catetere di abboccamento sulla cute, per la nutrizione enterale ed esso è visibile,”accartociato ” nel lume gastrico deteso…naturalmente la mancata connessione del catetere con la cute ha provocato un pn-peritoneo…TRIPLETE in vista ?

      • Jose Caceres says:

        Triplete is obvious! Hope to enjoy watching Barça-Juve with my good friend Lorenzo Bonomo.
        No comment about your diagnosis. Too early in the game.

        • genchi bari italia says:

          il prof Lorenzo Bonomo di Andria (BARI) è colui che mi insegnato l’Ecografia , nel lontanissimo 1983 e lui sa che la mia superspecialità è la radiologia “pediatrica” ….

    3. Borsuk says:

      Free air under right diaphragm. There is also dilatation of esophageus.
      Perforation of gastrointestinal tract after gastrostomy?
      Two things not compare – that patient is asymptomatic and it’s too easy for Caceres’ Corner:)

    4. gus says:

      Elevation of right diaphragm
      there is Air subcutaneous in soft tissue on the right with possible comunication with the right diaphragm
      complication post omentopexy?
      CRAZY ?

      • gus says:

        Plus i think i see Air fluid levels on esophageus and a (mass) opacity posterior of cardiac silhouette on lateral view, post transplant lymphoproliferative / lymphoproliferation disorder (PTLD)?

    5. NIK SOTOS says:

      I think its presence of air cause of the past surgery .If there is no clinical sintomps I think isth air from the surgery of the past month.

      • Jose Caceres says:

        The patient did not have any pneumoperotoneum one week before the current radiographs were taken.

    6. Fares says:

      I go with interposed bowel gas between the liver and the right hemidiaphragm (Chilaiditi’s sign). As i see some intestinal structures on the level of the liver.
      Chilaiditi is one of the D.D. of pseudopneumoperitoneum.

    7. Alaa says:

      Right sub-pulmonic effusion/ empyema

    8. Dr Hatem says:

      Pneumoperitonum , obliterated aorto pulmonary window + suggestion of prominent lt pulmonary artery

    9. Iffat Rehman says:

      There is mild elevation of right hemidiaphram. This may be normal in this case, upto 2interspaces may be normal, or related to post op phrenic nerve palsy (dissection during transplant surgery)… The linear shadow above diaphragm is most likely some form of linear atelectasis in this asymptomatic lady. Overlying right 7th posterior rib is surgically absent which may account for locally different ventilation.
      I’m not thinking of pneumoperitoneum as I feel there is some lucency above liver below diaphragm related to abdominal fat contiguous with fat on right side of liver. Also post gastrostomy leaks usually present within 24-48 hours. I have seen delayed cases up to a week. After 1 month, track has matured.

      I can see a tube projected over the upper abdomen with a discontinuity, its ends are not covered… Would like to compare with any prior post gastrostomy chest/abdomen radiograph to confirm if its intact and not fractured. The later is highly suspicious on this film

      Esophageal fluid level is expected due to reflux esophagitis and stricturing in scleroderma related esophageal changes.

    10. Yvette says:

      There is an air under right hem diaphragm, we can see air anterior and posterior to the area nuda. It is probably after PEG implantation or persistent leak of air. End of PEG is in duodenum. I don’t why there is small gap within the tube, but for me it is outside the body.
      In posterior mediastinum there is a small buble air with fluid level – probably small gastric herniation. Right dome is higher due to phrenic nerve palsy.
      I am looking forward unpatiently to your answer.

    11. Jose Caceres says:

      So far, nobody has mentioned the etiology of the pneumoperitoneum. Use the KISS method: air is coming either from ouside or from inside. Which is it?

    12. Fares says:

      I think the origin of this pneumoperitoneum is pneumatosis intestinalis.
      Especially with a patient has a past history of lung transplant.
      Pneumatosis cystoides intestinalis has ben reported after thoracic surgeries, when air travels through the mediastinum into the retroperitoneal space and then comes through the perivascular spaces in the intestinal wall.

    13. Amir says:

      The patient no symptomatic , its mean no dependent to her gastrostomy or perforation . But he is a SSc known case and there is a benign penumoperitoine that occure in Ssc after pnematisis cystoides intestinalis that show in this patuents in RUQ and central of abdomen in AP x ray…
      Its benign

    14. Fares says:

      Pneumatosis cystoides intestinalis (PCI) is a rare gastrointestinal complication in scleroderma. I supposed the air in this case may be escaped around the gastrostomy catheter.

    15. Yvette says:

      I think that air in peritoneum comes from outside. Because of mobile part of stomach it is imposible to keep stomach wall close to the abdominal wall, which is necessary to keep gastrostomy air – tight. The gap between these to walls causes persistent air leak around skin entrance of the tube.
      To support this assumptions -gastric entrance of the tube seems to be quite high in the left upper abdomen. It would be very inconvenient for the patent to keep it Just below the ribs.
      See you tomorrow Dear Muppet.