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QJM Advance Access originally published online on August 28, 2008
QJM 2008 101(10):825-826; doi:10.1093/qjmed/hcn086
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© The Author 2008. Published by Oxford University Press on behalf of the Association of Physicians. All rights reserved. For Permissions, please email: journals.permissions@oxfordjournals.org

The importance of never ignoring an unexplained metabolic acidosis

Y. Pasha, W.J. White, N.S. Chew and M. Banks

Chelsea and Westminster Hospital, Fulham Road, London, UK.

email: yasminpasha{at}doctors.org.uk

An 80-year-lady was admitted with coffee ground vomiting and productive cough. She was recently treated for community-acquired pneumonia with Augmentin. Clinical and biochemical deterioration continued despite antibiotics and within 48 h was requiring non-invasive ventilation with a climbing C-reactive protein (CRP), but normal white cell count. Chest X-ray showed right-sided consolidatory changes. Respiratory exam was compatible with aspiration pneumonia, arterial blood gas pre-BIPAP: pH 7.44, pCO2 3.8, pO2 7.0, lactate 1.3, SO2 89.8%, Base Excess (BE)–3.1, bicarbonate 19.7. Her abdomen was soft and non-tender with no organomegaly detected.

Gastroenterology referral was made for haematemesis. On inspection, however, the vomitus appeared bilious. On further questioning, her bowels had not opened for 7 days; however, she was still passing flatus. A naso-gastric tube was passed and 3.4l of fluid drained almost immediately. Her abdomen was now much softer and her breathing improved to the point of managing on room air, but despite normal renal function (non-diabetic) she had an unexplainable metabolic acidosis (pH 7.40, pCO2 3.34, pO2 9.1, bicarbonate 15.8, BE – 7). Abdominal X-ray (AXR) was unremarkable. An axial Computerized tomogram (CT) was performed. Her abdominal CT is pictured (Figures 1 and 2).


Figure 1
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  		Figure 1. Coronal abdominal CT view.

 

Figure 2
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  		Figure 2. Axial abdominal CT view.

 
Following imaging she rapidly underwent laparotomy despite absence of abdominal signs, other than mild distension.

What is the diagnosis?

Answer: This is an incarcerated femoral hernia. At laparotomy 3 inches of dusky cool bowel were resected, 2 inches contained areas of necrotic serosa, adjacent to ileo-caecal (IC) valve.

This case stresses the importance of never ignoring a metabolic acidosis in patient with normal renal function and no obvious cause. She proceeded to laparotomy as prompt CT was obtained, despite the apparently normal AXR of a patient clearly in clinical small bowel obstruction.

Learning points:

  1. Unexplained metabolic acidosis should never be ignored.
  2. AXR can be entirely normal despite clinical bowel obstruction.
  3. Once diagnosed, a cause for small bowel obstruction must be sought and resolved.
  4. Incarcerated and even necrotic hernias do not always present as an acute abdomen, particularly in the elderly.

Conflict of interest: None declared


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This Article
Right arrow Extract Freely available
Right arrow FREE Full Text (PDF) Freely available
Right arrow All Versions of this Article:
101/10/825    most recent
hcn086v1
Right arrow Alert me when this article is cited
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Right arrow Disclaimer
Google Scholar
Right arrow Articles by Pasha, Y.
Right arrow Articles by Banks, M.
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PubMed
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Right arrow Articles by Pasha, Y.
Right arrow Articles by Banks, M.
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