Q: 68 year old male was admitted to ICU for pneumonia six days ago. Patient is intubated, and on combo of sedation/analgesia. Patient has previous history of various abdominal surgeries and visible scars on abdomen. Patient continue to have high naso-gastric (NG) output. This morning patient abdominal exam shows distention as per previous days but with new finding of tympany with percussion over the upper right upper quadrant (RUQ) in liver territory. What is the biggest worry?
Answer: Free intra-abdominal air.
Ileus is common in ICU, particularly in patients with previous abdominal surgeries. But percussion over upper RUQ should stay dull as liver lies there. If percussion over the liver (precisely over anterior lower right rib cage and just below right rib cage) is tympanitic, it may indicate serious complication of intestinal perforation causing intra-abdominal air. Also, sign of tenderness with percussion may call for further evaluation for peritonitis.
Answer: Free intra-abdominal air.
Ileus is common in ICU, particularly in patients with previous abdominal surgeries. But percussion over upper RUQ should stay dull as liver lies there. If percussion over the liver (precisely over anterior lower right rib cage and just below right rib cage) is tympanitic, it may indicate serious complication of intestinal perforation causing intra-abdominal air. Also, sign of tenderness with percussion may call for further evaluation for peritonitis.
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