Shirazi B, Shamim M S, Bhatti A I, Shamim M.
Localized small bowel perforation - a Radiological Rarity.
J Pak Med Assoc Jan ;54(2):102-4.

A 28 year old male was seen with 24 hour history of constipation, abdominal distension, and vomiting. He also gave a history of intermittent high grade fever with rigors for the last one month. On examination his abdomen was mildly distended, tender all over with positive gut sounds on auscultation. Plain x-ray abdomen showed multiple air-fluid levels in the small bowel. The x-ray of the chest showed no evidence of free gas under the diaphragm. On admission his clinical diagnosis was subacute small bowel obstruction secondary to tuberculosis and conservative management was initiated. After about 8 hours of conservative management he passed stool, distension decreased but a localized area of distension, involving parts of umbilical, left iliac region and hypogastrium still persisted. A small bowel enema was performed to exclude a tuberculous stricture. The scout film of the small bowel enema showed the presence of a large lucent area along the left side of the abdomen. The upper limit of this area was seen at the level of L3 vertebral body on the left side. The lower limit of this region extended into the pelvis. Slightly distended small bowel loops were also noted in the left upper quadrant. Serial small bowel enema films revealed optimal opacification of the small bowel loops with contrast. There was generalized superior displacement of the small bowel loops predominantly along the left side of the abdomen. There was no apparent narrowing or stricture seen in the visualized segments of the small bowel. The displacement was being caused by the large radio-lucent gas filled area along the left side of the abdomen. Continued …

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