A

Abstract

peritoneal lavage was carried out, employing a peritoneal dialysis catheter, inserted through a small sub-umbilical incision in skin and linea alba. Five hundred ml normal saline were run in and returned clear. The catheter was removed and the skin closed with a single nylon stitch. Erect chest and supine abdominal films were normal. The patient was managed conservatively with intravenous fluids and regular careful observation. Two h after presentation, while her general condition was unchanged, palpation revealed very obvious surgical emphysema in the lower abdominal wall. On a second erect chest X-ray, gas was clearly demonstrated under both hemi-diaphragms and laparotomy was, therefore, undertaken. There was a considerable amount of bilestained fluid and gas in the retroperitoneal tissues around the duodenum, but only a small amount of free fluid in the peritoneal cavity. The duodenum was mobilised to display a 2 cm tear on the posterior surface of the junction of the second and third parts which was repaired. The patient made an uneventful post-operative recovery. The detection of surgical emphysema in the anterior abdominal wall clearly heightened suspicion of major intra-abdominal injury. The gas must have come from a perforated or leaking viscus. The possibility of iatrogenic perforation by the dialysis catheter was considered, but seemed unlikely as there was no faecal or bile-staining of the returning irrigant. Since initial X-rays were normal, slow leakage of gas from the retroduodenal tissues into the lesser sac and eventually into the general peritoneal cavity seems a likely sequence of events. In the supine patient, gas could rise to be expelled by contraction of the abdominal musculature through the small slit in the linea and into the subcutaneous tissues. This mechanism produced an unexpected but important clinical finding following initially negative peritoneal lavage which lead to the early detection of traumatic duodenal rupture, an injury in which diagnosis and treatment are commonly delayed for over 24 hours, and complications and mortality are correspondingly high.