An 18-Year-Old with Diffuse Abdominal Pain

Differential Diagnosis

• Pneumoperitoneum
• Pneumoretroperitoneum
• Subcutaneous emphysema

Diagnosis

The image shows mottled gas in the right lower quadrant, right upper quadrant along the liver edge, and left upper quadrant around stomach. The findings are concerning for pneumoretroperitoneum (gas in the retroperitoneal space).

Learnings/What to Look for

• Potential causes include trauma (penetrating wounds, surgical procedures, endoscopy, pelvic fracture), colon perforation (diverticulitis, carcinoma, rectal foreign body) and extension of a pneumomediastinum
• If localized, and with an air-fluid level, retroperitoneal abscess should be suspected and may be associated with the above listed causes or pancreatitis

Pearls for Urgent Care Management

• Pneumoretroperitoneum is best visualized on CT
• Medical management including fasting, hydration and consideration of IV antibiotics may result in spontaneous resolution
• Surgical management is indicated for larger perforations and more severe illness

Acknowledgment: Images and case presented by Experity Teleradiology (www.experityhealth.com/teleradiology).