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A16) Severe abdominal pain, diarrhea, and rigidity
Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.
Learning Outcomes
- Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with diffuse abdominal pain.
- Review the DDx considerations in a patient with diffuse abdominal pain.
- Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with diffuse abdominal pain.
History
A 62yo female presents to the ED with severe, sudden onset abdominal pain with nausea, vomiting, and diarrhea. The pain is constant and has lasted six hours. She has been experiencing dull, diffuse, post-prandial abdominal pain for the past year. She endorses a 40-pack year smoking history, T2DM, hyperlipidemia, and coronary artery disease.
Physical Exam
BP: 114/70, HR 99, RR 22, Temp 36.8C, O2 saturation 99%. General: Patient uncomfortable. Cardiovascular: heart with irregular rate and irregular rhythm. Abdomen: Diffuse abdominal tenderness. Involuntary guarding. Distended and rigid. Rebound tenderness.
Labs
WBC: 24 x 109/L (4.5 x 109/L – 11 x 109/L);
Lactic acid: 5mmol/L (nl < 2mmol/L)
Provisional Diagnosis
Select the Dx you believe is most appropriate
The patient with significant risk factors for atherosclerosis with a long-history of diffuse post-prandial abdominal pain may have chronic mesenteric ischemia. The new-onset severe pain is worrisome for acute on chronic mesenteric ischemia, like from ruptured plaque. This may also be from an embolic source, considering her likely atrial fibrillation on physical exam.
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Potential Acuity
What is your assessment of the likely acuity for this patient?
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This patient with requires emergent management. Mesenteric ischemia generally presents with “pain out of proportion to the physical exam.” However, the peritonitis on physical exam and lab findings suggests significant bowel ischemia, infarction, or perforation.
First Imaging Study
What is the first imaging study you will order?
A CTA of the abdomen and pelvis will allow for evaluation of the abdominal vasculature and perfusion of the abdominal organs.
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Pertinent Imaging Observations
Click on the links below to view images from the study, and assess these key findings as best you can.
CT Abdomen and Pelvis with Contrast
There is free intraperitoneal air.
There is no free intraperitoneal air, suggesting that there is no bowel perforation.
There is flow-limiting stenosis of the celiac artery.
There is severe narrowing and occlusion of the origins of the celiac artery.
There is flow-limiting stenosis of the superior mesenteric artery.
There is severe narrowing and occlusion of the origins of the superior mesenteric artery.
There is evidence of organ ischemia.
There is pneumatosis as evident by portal venous gas and air in the wall of the hollow abdominal organs in the distribution of the celiac artery (stomach) and superior mesenteric artery (small bowel, cecum). The spleen, which is also supplied by the celiac artery, also has focal hypodensities, suggesting ischemia.
View the full study if you'd like to take a look yourself.
Second Imaging Study
What is the next imaging study you will order?
No further imaging is needed as the diagnosis is confirmed with the CTA of the abdomen and pelvis.
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What is your Diagnosis now that you have seen the imaging results?
This patient has occlusive mesenteric ischemia either secondary to a thrombotic (possible considering atherosclerosis risk factors and chronic mesenteric ischemia) or embolic (secondary to atrial fibrillation) source. An embolic source (such as from the heart) is more likely considering that two vascular territories are involved. Non-occlusive mesenteric ischemia may be secondary to mesenteric vasoconstriction from hypoperfusion from shock, severe constipation, certain medications (like a patient having several vasopressors in the ICU), or illicit vasoconstrictive drugs (cocaine).
Current Acuity
Initially, you selected and we suggested acuity.
Has your concern for this patient changed?
The patient requires urgent workup and management.
Assessment and Plan
Please provide your assessment and plan for this patient
This is a 62-year-old female presenting with acute, occlusive mesenteric ischemia. Vascular surgery and acute care surgery should be immediately consulted for evaluation for revascularization, evaluation of the bowel, and possible resection of ischemic bowel. An echocardiogram should also be performed to evaluate for a cardiac thrombus as the source. An EKG should be performed to assess for atrial fibrillation.
Lessons Learned:
- Patients with risk factors for atherosclerosis are at increased risk for both acute and chronic occlusive mesenteric ischemia.
- Acute occlusive mesenteric ischemia may be secondary to an embolic source, like a heart thrombus. It may also occur due to rupture of a plaque.
- Acute mesenteric ischemia most commonly presents with “pain out of proportion to the physical exam.” However, there may also be peritonitis if there is significant bowel ischemia or perforation.
Socioeconomic Factors: - Patients with lower socioeconomic status commonly have a greater incidence of risk factors for mesenteric ischemia like diabetes mellitus and atherosclerotic disease.
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