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We have a 77 year old female history of

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hypertension and hypothyroidism presents with abdominal pain

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nausea and vomiting.

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So she endorses vomiting to the point of light-headedness and

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diffuse abdominal pain that actually is worse

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and over the course of several days.

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In the emergency room the vital signs were notable for hypotension to

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very soft blood pressures 91 over

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65 physical examination was notable

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for poor skin turgor and sunken eyes.

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So the patients ordered for CT of the abdomen with

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IV contrast.

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So what do we see here?

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This region there was really no evidence

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of acute abdominal pelvic pathology.

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However, there was an enlarged heterogeneous respiratorial

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lymph node measuring about 3.5 by

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1.9 centimeters.

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And so the findings were actually suspicious for a neoplastic process or

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biopsies recommended.

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the biofus performed under

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seed he guidance advancing to the

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site in question. So the procedure was thought to

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be technically successful at the time without immediate complications

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and samples that were

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obtained by the operator in question submitted them

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for two things.

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Because of the thought that perhaps this lymph node,

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which actually was necrotic could have

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been cancer.

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It was submitted in formalin for surgical pathology analysis.

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Because in the setting of lymph nodes that are in

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large in the body what the operator wanted to ensure was

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that this wasn't lymphoma. And so what

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did the operator send the sample for they sent it

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for flow cytometric analysis in a solution called rpmi?

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And that's important because any time lymphoma is suspected or

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is in the differential diagnosis. It

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is important for the operator to send the sample in

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rpmi for Flow side of metric analysis in addition to

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the Pathology.

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Analysis, which is usually submitted in

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formalin the patient was then discharged the same

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day without question.

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Two days later the patient actually presented the Ed with some

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abdominal pain chills and nausea.

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The vital signs were actually stable but the white count was that touch

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elevator just almost top normal at 11.5.

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no pair tinnitus on physical examination

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So the patient is again ordered for CT scan of the

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abdomen with IV contrast.

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So what do we see?

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So what jumps out at us?

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And so what was thought is that this little wispy appearance

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here?

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Surrounding the third and fourth portions

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of the duodenum were little concerning. It

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was also this question of tiny focus

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of air that was questionably extra luminal

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in nature. Then there was the unchange of parents of

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that right retroperative lesion.

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So what is the most likely cause of this patient's acute

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presentation?

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Hospital inquired gastrointestinal infection

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Is it necrotic generation of the mass?

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Is it androgenic micro perforation?

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Or is it an erosion of the mass into the duodenum?

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The question here is is there an actionic micro

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perforation?

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Stranding around the second third fourth

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portions of the duodenum focus of

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air thought to be extra luminal adjacent to

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an abdominal viscous.

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two days after a biopsy

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The question here is did a micro perforation occur in the

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setting of the biopsy.

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So this is something that we suspect and we need

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to evaluate for so this inflammation the

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free air experitoneal in

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nature is really concerning for whistle perforation

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because you really shouldn't have extra luminal.

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free air in the abdomen particularly in

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these retro practical portions of the duodenum

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So assuming a micropriation of the duodenum how made

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this complication best have been avoided?

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Should be in this particular case of use a

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lower gauge needle.

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Should the operator have used CT fluoroscopy?

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Should the operator place the patient in Trendelenburg?

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Should they have offered oral contrast

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Administration pre procedure in order to better visualize

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the gastrointestinal tract or the bowel?

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If you thought that oral contrast is

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something that could have been a benefit in this case you'd have

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been correct, of course during a CT

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guided biopsy. All contrast is

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not necessarily something that's administered what in

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this particular case given the

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appearance of the lesion.

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given its Regional location

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to the bowel

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the duodenum it would have particularly been very helpful for

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this operator to have the oral contrast in the

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bowel clearly delineating and expanding the

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ball ensuring that when they were looking for an appropriate

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site and safe trajectory in

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order to biops in the mass. They did not become confused on

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this non-enhancing non-contrasts study.

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Given the patients retro banana lesion

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to the bow, its proximity.

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The oil contrast may have been actually particularly helpful to delineate the

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visceral therefore helping the operator to avoid

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this and inadvertently injuring the duodenum.

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So what are next steps so surgery in

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the gastrointestinal services are consulted?

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And NG tube is placed in this patient and blood Spectrum antibiotics

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were initiated.

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And patient began to feel better and so surgical option

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was actually deferred.

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The team then sought further confirmation of

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a potential due on a leak by an upper GI

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series.

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An apologize series involves useful fluoroscopy

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and in ingestion of

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oral contrast agent and then in various projections

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evaluating to determine whether or not there's extra

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luminal extravisation of the

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oral contrast.

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And so what do they find the gastrographin seen passing

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through the first two third portions of the duodenum?

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They found that the gastric can do one only Coastal contrast were actually

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particularly unremarkable.

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And more so than anything else no evidence

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of a contrast like or perforation was

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seen.

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In case conclusion we find that the patient's

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pathology report returns showing in nearly as

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cellular sample would scan fibrone active tissue and this

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is consistent with the inadvertent duardinal targeting

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that is suspected in this particular case. The patient's

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acute abdominal presentation resolves with bowel

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rests and antibiotic therapy.

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The patient refuses for the follow-up of her retroperitoneal lesion.