My Belly Hurts…

Ok, this case is pretty complex – let’s get to it.

68 yo female presents to your ED by EMS c/o severe LLQ and epigastric abdominal pain for 3 days. She was discharged from your facility 21 days ago s/p cholecystectomy with concomitant mild gallstone pancreatitis. While here, her enzymes normalized and at D/C all prior ABD pain had resolved. She hasn’t been on antibiotics since surgery, and she has been able to eat without difficulty. Of note, she has lost 40lbs over last 8 months and has had an extensive history of prior bouts of abdominal pain – all of which were non-diagnostic until this recent bout of cholecystitis. States pain is 10/10, cramps, achy pain. Last BM 4 hours ago. Solid stool, no obvious discoloration, blood or mucus. Denies CP or SOB. Appears very uncomfortable.

PMHx includes:

Cholecystitis
Pancreatitis
Undifferentiated ABD pain
AAA at thoracoabdominal junction – 4.8cm last exam 30 days ago.
-has had this for 5 years
HTN
Hypercholesterolemia
Depression
Fibromyalgia
Smoker 2 packs/day 50+ years
Drinks 1-2 glasses of wine daily

PSHx:
Cholecystectomy
TAH-BSO

Meds:
Cymbalta
Hydrocodone with APAP
Xanax
Lisinopril
Lipitor
Atenolol
Multivitamins

Allergies: Morphine (hives per patient)

Vitals
BP: 210/112 R arm, 146/90 L arm
Pulse: 130-140 bpm at rest
RR 20  Temp 98.7F
O2 sat 96% on 2lpm via NC

Physical Exam

Gen: AOx3, appears very uncomfortable, dusky can’t find position of comfort. Appears frail amd unkempt. In obvious pain.
HEENT: patent airway, PERRLA, EOMI, bounding carotid pulses
Chest: Tachycardic, regular, no M/R/G. Mild wheezing all fields, no rhonchi or rales. Able to move air without significant distress
ABD: Soft, moderately TTP all quads with increased pain on palpating of epigastrium and LLQ. No rebound tenderness. Negative leg lift, Rovsing’s or CVA TTP. Bilateral femoral pulses equal but moderately weaker than carotids.
Ext: full ROM, no calf tenderness, no CCE. Very pale and dusky
Neuro: AOx3, no gross deficits noted

Ok, there is a lot going on here but at the same time, from an EM perspective, think about the case and put the following in perspective:

1)  Sick or not sick?
2)  What are the immediate life-threatening concerns?
3)  What is your differential diagnosis – most likely to least
4)  What one test do you want to do?
5)  What is the definitive treatment?
6)  What else do you want to know?

Remember, you have 2 nurses, a respiratory therapist, and a general surgeon on call.  If you can’t handle it, it needs to go elsewhere.

Below are some key studies to help with the case:
SMA IMA occlusion 20

SMA IMA occlusion1

SMA IMA occlusion 21

SMA IMA occlusion2

 

Posted in: Abdominal, Case Types

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9 Comments on "My Belly Hurts…"

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  1. Steve says:

    Steve, PA-S
    1) Sick or not sick? Sick…color, heart rate, and inability to get comfortable compels me to give this patient my immediate attention…
    2) What are the immediate life-threatening concerns? Dissecting aorta, may lead to rupture.
    3) What is your differential diagnosis – most likely to least
    a. Dissecting aorta
    b. ??? afebrile so I don’t think I am chasing an infection…diverticulitis was on my list but the blood pressure throws me off for that..unless we are looking at multi diagnosis. Lungs are a little tight but moving air ok and satting ok..
    4) What one test do you want to do? Ultrasound of the aorta
    5) What is the definitive treatment? Vascular surgery
    6) What else do you want to know? Pulsatile masses in abdomen? CBC with diff to make sure we’re not anemic, CMP to look at organ performance. Renal function may be impaired due to inadequate blood flow, like to know liver function in the back of my mind to see if that is being infused well enough.

  2. PM2PA says:

    Paramedic here, starting PA school in 2 weeks! Going to answer what I can.

    1) Sick or not sick?

    Definitely sick. If EMS didn’t take this patient in L&S I’d be worried.

    2) What are the immediate life-threatening concerns?

    I’m immediately worried about her heart rate and BP. Not exactly sure why the difference in BPs, but the high heart rate shows her heart is compensating greatly. The dusky extremities are very concerning given the above.

    3) What is your differential diagnosis – most likely to least

    Worsening AAA? Looks like it is going to rupture.

    4) What one test do you want to do?

    No idea. 12 lead to rule out MI?

    5) What is the definitive treatment?

    Surgery ASAP?

    6) What else do you want to know?

    Compliant with atenolol/lisinopril?

    Thanks, this site is great.

  3. MediMike says:

    1) Sick or not sick?

    Sickity sick sick. Sitting on the cliff edge…(in my mind!)

    2) What are the immediate life-threatening concerns?
    Insanguination
    3) What is your differential diagnosis – most likely to least
    Dissecting aorta
    Ischemic bowel due to arterial occlusion
    4) What one test do you want to do?
    CBC to check crit or…Some type of imaging study that I’ll be able to understand!
    5) What is the definitive treatment?
    Surgery
    6) What else do you want to know?
    How to interpret these images…

  4. Dan S says:

    Dan here. Starting PA school in a month, but this looks fun and I can’t resist.

    1) Sick, the guarding, dusky appearance and abnormal vital signs do it for me.

    2) I am thinking ruptured aneurysm and/or associated dissection to mesenteric arteries is the most life threatening concern

    3) in terms of DDx, I am most concerned with unstable/ruptured aneurysm w/ or w/o rupture, pancreatitis, post-surgical peritonitis (although unlikely with no fever, abdominal rigidity or rebound tenderness)

    4) Tests: CT w/ angiogram is the one test I want to (which you have and looks to have possible blood loss at the junction of thoracic/abdominal aorta).

    5) Definitive treatments for aneurysm are surgical correction with immediate aggressive HTN management, and blood/fluid restoration if needed. Pain medication may also help with hypertension.

    6) I would also want CBC w/ diff, lipase, type and cross (just in case), CMP, PTT/PT (for possible surgery)

    All I can think about right now. Thanks

  5. Great idea on the U/S – that was the first thing I reached for as well.

    For the diff dx, we have:
    Rupturing AAA
    Diverticulitis
    Mesenteric Ischemia due to obstruction
    pancreatitis
    Post-surgical peritonitis or other associated complication (leak for example)

    On the CT scans (and reconstructions), it is easy to see the aorta. It is a little hard to make out the fine detail though at the thoracoabdominal junction. I will note though, that there is no change in size of they AAA and no new AAA. Also of note, her BP and tachycardia dropped significantly after a single dose of narcotics and 1 liter of NSS. However, her underlying pathology is very real.

    If you look at all of the CTs, what do you notice missing from them? That is the key to the case. CTA is all you need for ultimate diagnosis for this case, and in reality, she needs an OR more than anything. Her 12-lead was fine (other than the tachycardia).

    G

  6. Alisha, PA-S says:

    This is interesting. With her history and the unequal BPs, I’d jump to ruling out a dissection of her AAA, leading me to the CT first…. but I think also with the differential we have to include mesenteric ischemia. If she has been experiencing episodic pain, it isn’t unreasonable to think she’s been having some microemboli or something… I haven’t seen except one of these CTA scans before, but from my knowledge of anatomy, wouldn’t the SMA show up like the other major arteries? I don’t see anything that resembles the SMA (or IMA for that matter)… but I don’t know if it’s just because I haven’t gotten good at looking at these scans yet? Thanks for posting these :)

  7. Dan S says:

    Wouldn’t something resembling the spleen show up as well? I have not seen many CTA’s before, but I am not sure I see it.

    • Dan S says:

      Looking at the CT, it looks as though a part is missing just inferior to the renal arteries in the abdominal aorta. Still thinking dissection or thrombosis w/ possible mesenteric ischemia. Any further clues?

  8. Hi Dan,

    Been tied up with AAPA.

    Couple of other things tht weren’t asked but were Germaine:

    Lactate was 6.1
    WBC was 32k
    Cr was 1.8

    Final diagnosis was SMA and IMA occlusion with severe stenosis or R iliac as well. No change in AAA. Last I knew the patient went to the OR. ThIs was a great case.

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