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  • AutorenbildMichael Mutter

Abdominal pain after diving

Case vignette

The 54-year-old man presented to the emergency department on an island in the Indian Ocean with acute abdominal pain. He was in a dramatic condition with signs of shock with hypotension (low blood pressure), bradycardia (slow pulse) and hypothermia (hypothermia), was slightly confused and had difficulty giving information about himself. The abdomen was hard and tense, the abdominal skin mottled. The right leg was partially paralyzed and sensation was impaired in both legs. The condition was stabilized with the administration of fluids.


Image template: Patrick Rhyner, Tauchschule H2O

Because an acute, severe illness of the abdominal organs was suspected, such as an aortic dissection (aortic tear) or an ileus (intestinal obstruction), an emergency ultrasound scan was performed first, followed by a CT scan. These showed no acute pathologies of the abdominal organs. However, a considerable amount of air was found in the large intestinal veins. The patient was then questioned again about his medical history. He now reported that on the same day he had undertaken 3 dives with compressed air to depths of 23 m, 22 m and 21 m with dive times of between 41 and 57 minutes and surface intervals of 65 and 105 minutes respectively. He had arrived the evening before, partied with friends and consumed a several whiskeys. The dive computer had not displayed any alarms during the dives.


A diagnosis of abdominal DCI (decompression sickness of the abdomen) was made and the diving medical officer (DMO) at the nearby naval base was notified. Under maximum oxygen administration via a mask (15 l/'), the symptoms of paralysis and the sensory disturbances in the legs improved within minutes. The patient was immediately transferred to the hyperbaric chamber at the naval base, where treatment was initiated in line with Navy Table 6. Already during the second phase of the treatment protocol, the patient experienced a significant improvement in his abdominal symptoms. The treatment was extended to 2.8 bar ambient pressure up to the maximum permitted treatment time. Overnight monitoring was uncomplicated with only minor abdominal pain. The hyperbaric chamber treatment was repeated the next day. During this, the symptoms disappeared completely. 3 days after the onset of the illness, a new CT scan showed no more air in the abdominal veins. The patient remained symptom-free with normal bowel function. He was discharged from hospital with the recommendation not to fly for at least 3 days and not to dive again for at least 30 days and only after a medical diving consultation.


Discussion

Abdominal DCI is a rare manifestation of a decompression incident. The resulting gas bubbles lead to blockage of the large intestinal veins and ultimately to a coagulation disorder, which has the same effect as a mesenteric vein thrombosis (clot formation in the intestinal veins) with the acute risk of intestinal necrosis ( destruction of the intestine). Shock and severe abdominal pain are the result. In addition, the patient also showed symptoms of spinal DCI (spinal cord involvement). Factors favoring DCI in this case were the repetitive dives and dehydration as a result of the alcohol-laden party the evening before the dive. Due to the extent of the bubble formation and the skin findings of a cutis marmorata, it must be assumed, until proven otherwise, that a PFO (patent foramen ovale) was also a contributing factor to the DCI.


Take home messages

  1. Decompression illness can affect practically all organ systems and mimic many other diseases.

  2. At the slightest suspicion of DCI, high flow oxygen should be given without delay (15 l/' as in this case).

  3. If you have been diving in the last few hours or days, it is essential for a correct medical assessment that you inform the medical team, even if the emergency treatment is (supposedly) not for a diving problem.

  4. A DCI can occur despite formal adherence to a correct diving profile.

  5. Repetitive dives and dehydration due to alcohol consumption are classic risk factors for DCI on vacation. Moderation of alcohol consumption, conscious hydration with non-alcoholic drinks and the use of Nitrox all help to counteract this.


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