A 38-year-old morbidly obese woman underwent a subtotal small bowel resection at her local hospital for intestinal infarction due to polyarteritis nodosa. She subsequently developed sepsis and pulmonary insufficiency and was transferred to our hospital, After hemodynamic stabilization, a laparotomy, with near-total small bowel resection and drainage of intra-abdominal abscesses, was performed. Postoperatively, she developed pulmonary, renal, and hepatic failure with an accompanying encephalopathy Cultures of sputum grew Pseudomonas sp. A right pneumothorax developed and was treated with tube thoracostomy. She then developed and was treated with tube thoracostomy. avandia generic
She then developed a pulmonary embolism and protracted respiratory failure. The portable chest roentgenogram demonstrated the right chest tube, right pleural thickening, and two thin walled cystic structures in the right perihilar and suprahilar areas. The left lung appeared normal (Fig 1). We felt that the patient’s rapidly deteriorating clinical status warranted an immediate CT for further evaluation of the cavitary disease. In the right hemithorax, the CT (Fig 2) demonstrated a loculated, thick-walled, anterolateral pneumothorax; multiple cavities, none demonstrating air fluid levels; and a possible bronchopleural fistula. A thoracostomy tube injection (Fig 3) confirmed the presence of the bronchopleural fistula and demonstrated its origin from the axillary subsegmental bronchus of the right upper lobe. Because of the CT findings, antibiotic therapy was changed, chest tubes were repositioned to facilitate evacuation of the pneumothroax, and over the next week, her pulmonary status improved significantly. One month later, she was discharged to her home, improved but with continued total parenteral nutrition.
Figure 1, Case 1. The right thoracostomy tube, the right pleural thickening (arrowheads), and the two perihilar cystic lucencies on the right are demonstrated. None of the traditional signs of penumothorax is seen.
Figure 2, Case 1. Upper, CT at the level of carina at lung window demonstrates the axillary subsegmental bronchus (white arrow) just shy of the pneumothorax. The two small prehilar right sided cystic lucencies communicating with the anterior segmental bronchus of the right upper lobe are cavitary lesions (arrowheads). Lower, 1 cm below the carina at lung window More of the larger of these two perihilar cystic lucencies can be seen (black arrowhead) in direct communication with the anterior segmental bronchus of the right upper lobe. Subpleural bronchiectasis of the right upper lobe is also seen.
Figure 3, Case 1. Thoracostomy tube injection (open arrow) demonstrates contrast freely entering the axillary subsegmental bronchus of the right upper lobe, then draining centrally to the right upper lobe bronchus.