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19 y.o. man who presents w/ six hours of severe epigastric and upper abdominal pain, radiating to his back. He volunteered that he had been smoking cocaine (crack) one hour prior to the start of his symptoms. Social history is positive for EtOH (six drinks daily), tobacco, and cocaine abuse. He has no prior medical or surgical history and no previous abdominal complaints.
• Vital signs: stable, afebrile, with mild sinus tachycardia.
• Abdomen is soft, non-distended with positive bowel sounds, but with positive guarding and rebound tenderness.
• WBC count eleated at 15.1, lactic acid 2.5 mmol/L (high), potassium 6.4 mmol/L (critical high), urinalysis positive for protein, ketones and urobilinogen.
Single AP supine view of abdomen demonstrates a thin line of gas in the right upper quadrant, concerning for free air. Mildly distended prominent centralized loops of small bowel are seen in the mid abdomen which may represent a regional ileus. Gas is seen outlining the left psoas muscle.
Single AP frontal view of chest demonstrates a subtle area of lucency under the right hemidiaphragm suspicious for free air in the abdomen. No pneumothorax is noted.
Abdominal free-air:
• Perforated hollow viscus (eg. gastric - peptic ulcer disease)
• Ischemic enteritis
• Pneumomediastinum/pneumothorax decompressing into abdomen
• Gas-forming bacterial peritonitis
• Penetrating trauma to abdomen
Dx: Pre-pyloric Gastric perforation, cocaine abuse
Dx Confirmed by: Exploratory Lapartomy
- Read Due to high clinical suspicion, acute abdomen in the setting of crack abuse, and with positive imaging findings indicating pneumoperitoneum, our patient underwent emergent exploratory laparotomy and subsequent repair of his pre-pyloric perforation. No findings of ulcer disease were found. The clinical presentation was classic for gastric perforation from crack abuse.
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