"Coffee grounds" through the chest tube.

A 78-yr-old Saudi male was admitted having had epigastric pain and vomiting for 3 days. The patient was unable to give a clear medical history; however, he described the pain to be severe, colicky, nonradiating and aggravated by food. On the day of admission, he had noticed a small amount of fresh blood in the vomitus. The family indicated that he had had a long-standing history of intermittent abdominal pain, mainly related to food, for the past 25 yrs. Indeed, he had been admitted to the surgical ward 6 yrs previously with similar pain and was suspected to have a perforated duodenal ulcer, but recovered with conservative treatment. A few weeks after discharge he underwent upper gastrointestinal endoscopy, which showed oesophageal and duodenal diverticula and duodenitis. He was treated with ranitidine for 6 weeks with improvement and did not attend any further follow-up until this presentation. The physical examination results were unremarkable apart from pallor and epigastric tenderness. The haemogram was consistent with severe microcytic hypochromic anaemia. Serum electrolytes, urea, creatinine, amylase and random blood glucose levels were within the normal range. The initial chest radiograph is shown in figure 1. The following morning, the physician on duty was called to see him owing to severe respiratory distress. Examination of the chest showed dull percussion notes on both lung bases and numerous crackles. The chest radiograph showed large bilateral pleural effusions and a rightsided apical pneumothorax. Chest tubes were inserted and drained rusty brown fluid with clots (coffee groundslike).