Cáceres’ Corner Case 247 – SOLVED

Dear Friends,

Today´s radiographs belong to a 53-year-old man with abdominal pain.
What do you think?

Dear Friends,

showing today axial and coronal CI images of the abdomen. What do you think?

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Findings: PA and lateral chest radiographs show a large gastric bubble, with abundant stomach contents (A, arrow). In addition, there is a prominent air-fluid level in the right upper quadrant (A-B, red arrows), A small rounded metallic opacity is projected over it in the lateral view (B, circle).
The findings are suggestive of gastric outlet obstruction. Duodenal obstruction is unlikely because the second air-fluid level is anterior in the lateral projection. The little rounded metallic opacity suggests the possibility of a foreign object.

Coronal and axial CT show a food-filled stomach with a balloon located in the antrum (C-D, arrows).

Upright abdominal radiograph (E), parallels the gastric findings in the coronal CT (F).
(Showing plain film of the abdomen as an homage to Dr Genchi Bari).
 
A gastric balloon for obesity had been placed two weeks earlier.

Final diagnosis: balloon causing stomach outlet obstruction. This complication occurs in less than 1% of cases (*).
 
Congratulations to Olena, who was the only one to see the balloon valve and to Archanereddyt who made the final diagnosis.
 
Teaching point: as stated in case 242, always include iatrogenesis in your differential diagnosis. Reviewing the literature I discover an interesting fact: the saline in the balloons is tinted blue. If the urine becomes blue or green, is a sign of balloon deflation.
 
Incidentally, malicious rumors about the radiographs belonging to Miss Piggy are totally false!
 
(*) Gastric outlet obstruction secondary to orbera intragastric balloon. SA Kook and J Hammond. JSCR 2018; 10: 1-3

22 thoughts on “Cáceres’ Corner Case 247 – SOLVED

  1. Good morning!

    I dont find anythig relevant in the thorax except the piercing on the right nipple, but there is a air-level on the gastric fundus and another one in the right upper quadrant (probably in the gastric antrum), so a pyloric/duodenal obstruction must be rule out.

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  2. …mitico Prof….immagine di doppia bolla, gastrica e duodenale, in adulto….pancreas anulare, compasso aortomesenterico,ernia di Lesser, grosso diverticolo duodenale….perché’ non vi è’ una diretta addome?….aspettando il mercoledì’ delle coppe….

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  3. I suppose it could be large bowel obstruction (probably colon ascendens).

    On lateral view I see also small metal ring structure – it is well seen projecting over the air in bowel. There are also multiple smaller hyperlucencies – I suppose it is normally aerated small bowels which are pushed by increased in volume large bowel.

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  4. The double bubble projected on the abdomen is striking, it reminds of the duodenal atresia typical of newborns. It could be an intestinal obstruction. Does the patient have previous surgeries? Perhaps it could be a complication of bariatric surgery?

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  5. Than I suppose it could the imaging of complications after surgical procedure but have no idea which.
    This metal structure is only seen on lateral view more ventrally so it could be on skin, in subcutaneous tissue/muscles.
    Or maybe patient has had appendectomy? (Appendix has different locations)

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  6. Or it could be some issue with hepatobiliary system… well, everything, which is anatomically presented there (too much typing).

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  7. Hello!!!

    The small metal ring structure may be a biliary prothesis, so perhaps the patient has a neoplastic process at the Vater ampoule afecting the duodenum?

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  8. and the medical device – could be something after gastrostomy (imposed artificial outdoor gastric fistula – and then it was pulled out somehow – clinical history – ?) than it could be cancer patient (esophageal ca – ?)

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  9. ….grazie PROF. della dedica sulla radiografia dell’addome….avevo pensato ad una complicanza della chirurgia bariatrica….auguri x i blugrana ! Noi siamo ancora in C !

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