A 56-year-old man comes to the emergency department due to worsening abdominal discomfort and distension. The discomfort is diffuse and began 1 day prior, after the patient woke up from a night of heavy drinking that included a fall in which he struck his lower abdomen. He has also had increasing abdominal girth over the past day. Medical history includes alcohol use disorder and hypertension; there is a remote history of appendectomy. Review of systems is negative for fever or vomiting but positive for inability to void. Temperature is 36.7 C (98.1 F), blood pressure is 158/90 mm Hg, and pulse is 90/min. Heart and lung sounds are normal. The abdomen is distended, mildly tender to palpation diffusely, and dull to percussion with a positive fluid wave. Laboratory results are as follows: Which of the following is the most likely diagnosis in this patient?

Question

A 56-year-old man comes to the emergency department due to worsening abdominal discomfort and distension.  The discomfort is diffuse and began 1 day prior, after the patient woke up from a night of heavy drinking that included a fall in which he struck his lower abdomen.  He has also had increasing abdominal girth over the past day.  Medical history includes alcohol use disorder and hypertension; there is a remote history of appendectomy.  Review of systems is negative for fever or vomiting but positive for inability to void.  Temperature is 36.7 C (98.1 F), blood pressure is 158/90 mm Hg, and pulse is 90/min.  Heart and lung sounds are normal.  The abdomen is distended, mildly tender to palpation diffusely, and dull to percussion with a positive fluid wave.  Laboratory results are as follows:  Which of the following is the most likely diagnosis in this patient?

Quizplus · Accepted Answer

11ec25c8_d956_e47c_bc81_2bbdd3f470d9_MD0003_00 This patient with blunt lower abdominal trauma incurred during a night of heavy drinking (eg, likely full bladder) now has inability to void, abdominal distension with ascites on examination (eg, dullness to percussion, positive fluid wave), and elevated blood urea nitrogen (BUN) and creatinine. This presentation is most concerning for intraperitoneal bladder rupture. Blunt trauma can cause a full bladder to rupture at its weakest point, the dome. As a result, urine is diverted from the urinary tract into the peritoneal cavity (eg, inability to void). Although rupture is often painful, it may be masked by acute intoxication, as in this patient, or distracting injuries (eg, polytrauma). Following rupture, peritonitis often does not develop acutely because urine is typically sterile. Therefore, patients may not seek medical attention until after urine has accumulated within the peritoneal cavity, at which point the abdominal distension from urinary ascites and the increased BUN and creatinine from peritoneal reabsorption may be present. Retrograde cystography can confirm the diagnosis. (Choice B) Severe cirrhosis (eg, alcoholic liver disease) is commonly complicated by ascites, which can present with increasing abdominal girth and a positive fluid wave on examination. However, this is typically associated with low serum albumin, which is synthesized exclusively in the liver. In addition, symptoms of ascites typically develop over the course of weeks to months versus the 1 day in this patient. (Choice C) Rhabdomyolysis, which may occur with both short-term alcohol intoxication (eg, immobilization) and long-term alcohol abuse (eg, electrolyte disorders), can cause acute kidney injury with elevated BUN and creatinine. However, dark urine is typical, and ascites is not expected. (Choice D) Although blunt abdominal trauma can cause small-bowel perforation acutely or subacutely (eg, small-bowel contusion progressing to ischemic necrosis), perforation more commonly presents with a systemic inflammatory response (eg, fever, tachycardia) and peritonitis (eg, abdominal rigidity). (Choice E) Splenic injury (eg, laceration) is one of the most common complications of blunt abdominal trauma. Although significant splenic bleeding can cause abdominal distension, it is typically accompanied by signs of hemorrhagic shock (eg, tachycardia, hypotension). This patient's mild anemia is likely attributable to chronic alcohol use. Educational objective: Blunt trauma to a full bladder can cause it to rupture at the weakest point, the dome. Diversion of urine from the urinary tract (eg, inability to void) into the peritoneal cavity can cause urinary ascites and increased blood urea nitrogen and creatinine from peritoneal reabsorption. References: Blunt bladder injury. (http://www.ncbi.nlm.nih.gov/pubmed/23522505) Pseudo-renal failure: bladder rupture with urinary ascites. (http://www.ncbi.nlm.nih.gov/pubmed/26590189)

A 56-Year-Old Man Comes to the Emergency Department Due to Worsening