Image Challenge | Difficulty Breathing

Posted on October 3, 2013


An 80 year old male with multiple medical problems (including CAD, COPD and atrial fibrillation) is undergoing evaluation for progressive early satiety and vomiting after meals for the past year.  A peri-pancreatic mass causing extrinsic compression of the gastric outlet near is discovered on abdominal imaging, and upper endoscopy with endoscopic ultrasound and fine needle aspiration of the mass is performed for cytology.  About 4 hours after the procedure, the patient develops respiratory distress and you are called to evaluate him.

The patient is alert, tachypneic (respiratory rate 30), and tells you he is not in pain.  Auscultation of the lungs reveals poor air movement throughout, but no wheezes or crackles.  His abdomen is scaphoid, soft, and non-tender.  The patient’s heart rate is 130-150 bpm and the rhythm is atrial fibrillation, with a blood pressure of 110/66 mmHg.  Fingertip pulse oximetry dropped to 88% and supplemental oxygen was applied before your arrival.  He is afebrile.  A chest x-ray is obtained:

diaphragm air2

What is the most likely diagnosis?

  • A) Pneumoperitoneum (free air in the abdomen [from small bowel perforation])
  • B) Pneumomediastinum (free air in the thorax [from a ruptured esophagus])
  • C) Aspiration pneumonia
  • D) Aspiration pneumonitis

Leave your answer below & check back in 24-48 hours for the explanation.  Good luck!

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Posted in: Medicine