Presentation
Presents unable to walk after jumping off a boat. A ruptured bladder was repaired two days ago, and the abdomen is distended this morning.
Patient Data
There is increased soft tissue opacity and poor peritoneal detail within the abdomen. The peritoneal detail has a mottled apperance, with areas of increased and decreased opacity. The abdomen is also distended, and there are surgical staples along the ventral abdomen.There are small triangular gas bubbles near the bladder, consistent with previous surgery. The bladder is not clearly visible.
A positive contrast cystogram was performed using non-ionic contrast medium. The contrast exits the bladder at the cranial pole, dissects between the mesenteric folds, and pools in the mid-portion of the abdomen.
Ruptured bladder and uroperitoneum.
Case Discussion
The ruptured bladder was repaired initially, but recurred two days after surgery. A positive contrast cystogram is the study of choice in this case. Non-ionic contrast medium is less irritating to the peritoneal cavity than ionic contrast medium. At surgery, the bladder wall was necrotic and friable.
The mottled peritoneal detail was suggestive of peritonitis, and the distension incicated effusion. The mottled detail is often seen in peritonitis and carcinomatosis. At surgery, the mesentery, omentum and peritoneal serosa were inflamed and thickened.
When performing the study, it's helpful to take several radiographs during injection to see the point of exit of contrast medium. If a significant amount is in the peritoneum, it can obscure the point of rupture.
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