guayoman
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34 male. Car accident. Epigastric pain. Hemodynamically stable. No obvious injury. Abdominal XR=Retroperitoneal air. Which is te investigation of choice to confirm the suspected diagnosis?
A. Abd CT
B. Diag Peritoneal Lavage
C. Exploratory Laparo
D. Abd CT with contrast
E. Abd USG
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| juanma0
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ok. so he has blunt abdominal injuryand hemodynamically stabel, so we have time to study him. Epigastric pain and retroperitoneal air point to pancreatic injury. CT scan is the best for evaluating retroperitoneum. Hmmm, I think CT w/contrast D, cuz there isno contraindication to its use and will outline the pancreas better.
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| achilles
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this cud also be a duodenal injury(in addition to a pancreatic injury which can present in a similar way) as suggested by the nature of trauma and retroperitoneal air. because it is blunt abd trauma the injury most likely wud involve the 2nd part of the duodenum.
i'll go for CT scan with contrast.
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| som
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D is right
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| guayoman
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So if you already know there is air in the retroperitoneal cavity, why not go ahead and open the guy to repair the hole?
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| study_ing
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we dont know the source of air nor the extent of the injury. hence we do the ct
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| tolito
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ct with contrast. 
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| nadiabarati
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this Q is interesting and fair. Thats why I guess it must be NBMEs or UW? Please do lable them for people who are gonna take them later.
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| vikram25
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Answer is CT with contrast because it will outline the pancreas better, otline the gut and it will reveal status of other abdominal organs
surgerymcq.co.nr
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| nadiabarati
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C
check out page.136 kaplan surgery case.37
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| juanma0
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I think we all agree that subdiaphragmatic air is indication for exploratory lap, but not so sure for retroperitoneal air. (hey nadiabarati, case u mentioned has subd air and is hemodynamically unstable, different setting)
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| nadiabarati
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So what is the difference? Doesn't retroperioneal air mean hallow viscus perforation?
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| tolito
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am thinking the question asks about INVESTIGATION of choice to CONFIRM diagnosis and not next step in management.
an exp lap is notorious for missing retroperitoneal injuries cos exp lap takes a look at the intraperitoneal structures. you may suspect a retroperit injury from blood behind perit but in a perforated viscus, you may miss the organ.
my 2 cents (from experience but will look up what the books say)
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| tolito
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an interesting article
http://www.ijccm.org/article.asp?issn=0972-5229;y...
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| nadiabarati
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thanks a lot. I think you're gonna join club 99 for step 1...
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| tolito
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| Sea_gull
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| ed222
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CT without contrast first because it can be dangerous to give contrast in someone we suspect has a rupture due to abdominal trauma.
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| fox
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This looks like perforation of 2nd part of deuodenum.....will pancreatic injury cause retroperitoneal air? I thought only a hollow viscus rupture can release air.
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