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Sat Aug 7 23:06:33 BST 2004

Has anyone experienced such a scenario?
51yo male invloved in high speed MVC with multiple injuries, including Grade IV liver injury, rib fractures, pneumothorax and humerus fracture. He received 2 units of blood and was hemodynamically stable from then on. CT abdomen/pelvis shows a large intrahepatic hematoma, which is for the most part contained, a moderate amount of free intraperitoneal fluid and 2 stones in the pelvis, free in the peritoneal cavity but outside of any hollow viscus. 
He was not operated on immediately, the surgeon fearing that he would free a conatined hepatic hemorrhage by taking out the gallbladder, but it was the suspicion that the stones were from a ruptured gallbladder. When I was asked to assume the patient's care four days later, he promptly became febrile to 103, developed profound hypoxemia and the diffuse, bilateral infiltrates characteristic of ARDS. His abdominal exam became more tender, according to the residents. 
I took him to the operating room where, at exploration, the only abnormality was old blood. The liver hematoma was contained and not actively bleeding, the gallbladder was thickenied but there was no perforation, there was no bile staining anywhere, and the bowel from EGJ to rectum was normal, as was the bladder. There were in fact, 2 stones free in the pelvis. I took his gallbladder out and put in a feeding tube.
I've not seen stones free in the peritoneal cavity with no other pathology. Anyone out there have? I'm certain there was not an injury that I missed. 
Thanks
Rick Pomerantz, MD
Trauma Director, St. Joseph Mercy Hospital Ann Arbor
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