EC Clinical and Medical Case Reports

A 59-year-old male presented with acute abdominal pain and referred left shoulder pain (Kehr’s sign), suggestive of diaphragmatic irritation. Imaging studies confirmed pneumoperitoneum, leading to the diagnosis of an anastomotic leak following a complex surgical procedure for locally advanced gastric adenocarcinoma. The patient’s initial surgery included a distal gastrectomy, right colectomy, and atypical hepatectomy. Post-operatively, he developed significant complications, including recurrent infections and pneumoperitoneum, necessitating multiple surgical interventions. This case highlights the diagnostic significance of Kehr’s sign in identifying diaphragmatic irritation and the critical role of imaging in confirming pneumoperitoneum. Prompt surgical management was essential in addressing life-threatening complications and achieving patient stabilization. These findings underscore the need for vigilance in post-operative monitoring and a multidisciplinary approach to managing complex oncologic surgical cases.

 Keywords: Kehr's Sign; Pneumoperitoneum; Postoperative Complications; Gastrointestinal Perforation

1. V Klimpel. “Does Kehr’s sign derive from Hans Kehr? A critical commentary on its documentation?”. Der Chirurg1 (2004): 80-83.
2. Olivier A Pluut., et al. “Spontaneous, atraumatic rupture of the spleen in a young man”. Nederlands Tijdschrift voor Geneeskunde 159 (2015): A8392.
3. Sutton CD., et al. “Kehr's sign - a rare cause: spontaneous phrenic artery rupture”. ANZ Journal of Surgery 12 (2002): 913-914.
4. Steele DC., et al. “Splenic rupture following colonoscopy”. Digestive Diseases and Sciences 1 (2017): 72-75.
5. Taj H., et al. “Extracapsular hepatocellular adenoma: a diagnostic dilemma”. Cureus6 (2020): e8928.
6. H Slimani., et al. “Kehr’s Sign. A Clinical Sign that can Save!”. Annales Françaises de Médecine d'Urgence 7 (2017): 205.
7. Söyüncü S., et al. “Traditional Kehr's sign: Left shoulder pain related to splenic abscess”. Turkish Journal of Trauma and Emergency Surgery1 (2012): 87-88.
8. Brandon C Chapman., et al. “Postoperative pneumoperitoneum: is it normal or pathologic?”. Journal of Surgical Research1 (2015): 107-111.
9. Tiffany Nicole Tanner., et al. “Pneumoperitoneum”. Surgical Clinics of North America 5 (2018): 915-932.
10. Radu Seicean., et al. “Anastomotic leakage after gastrectomy for gastric cancer”. Journal of Gastrointestinal and Liver Diseases 4 (2023): 526-535.