WIDI - A31) Epigastric pain

A31) Epigastric pain

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 epigastric pain.
Review the DDx considerations in a patient with epigastric pain.
Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with epigastric pain.

History

A 55-year-old male presents to the ED due to epigastric pain. The patient reports one year of epigastric pain that is relieved with food, nausea, and early satiety. He endorses chronic back pain for which he takes high daily doses of ibuprofen. He also has a 60-pack smoking history. He presents today due to sudden onset worsening of symptoms. His abdominal pain is usually a 3/10 and is now a 10/10 and radiates to his back and right shoulder.

Physical Exam

BP: 125/90, HR 99, RR 19, Temp 98.6, O2 saturation 99%. General: Uncomfortable and in pain. Abdominal: Significant upper abdominal tenderness. The patient is involuntarily guarding his abdomen. There is rebound tenderness.

Labs

Hgb: 14g/dL (nl: 13.8-17.2g/dL)

Provisional Diagnosis

Select the Dx you believe is most appropriate

Gastric ulcer

Duodenal ulcer

Perforated gastric ulcer

Perforated duodenal ulcer

The patient’s dyspepsia with history of NSAID use and smoking is consistent with an ulcer. It is most likely perforated considering the sudden worsening of symptoms with peritoneal signs. The location is likely duodenal considering it is improved, and no worsened with food, as compared to a gastric ulcer.

Well done. You were correct

Potential Acuity

What is your assessment of the likely acuity for this patient?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

Well done. You were correct

The patient requires urgent workup and management.

First Imaging Study

What is the first imaging study you will order?

KUB

CT chest, abdomen, and pelvis with IV contrast

CT chest, abdomen, and pelvis without IV contrast

MRI of abdomen

A CT scan with IV contrast should be ordered to evaluate for signs of a perforated ulcer. A KUB is not necessarily sensitive for free air as compared to a flat and upright abdominal X-ray.

Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

CT chest, abdomen, and pelvis with IV contrast

There is free intraperitoneal air

Yes

There are locules of free intraperitoneal air anterior to the liver.

There is a locule of air adjacent to the duodenum

Yes

There is a locule of air adjacent to the duodenum suggesting a duodenal perforation.

The duodenum is normal

Yes

There thickening of the duodenum and inflammatory changes in the duodenum with hyperenhancing mucosa and surrounding fat stranding. There is also discontinuity in wall of the duodenum suggesting a perforation.

There is free intraperitoneal fluid

Yes

There is free intraperitoneal fluid, likely representing gastric contents and reactive ascites in this clinical context.

View Report

Watch our video

View the full study if you'd like to take a look yourself.

Launch Dicom

Second Imaging Study

What is the next imaging study you will order?

Abdominal ultrasound

Abdominal MRI

None

No further imaging is required as the diagnosis is made with the CT scan.

Well done. You were correct

What is your Diagnosis now that you have seen the imaging results?

Perforated duodenal ulcer.

Septic shock secondary to perforated duodenal ulcer

This patient does not meet criteria for sepsis. However, they have a perforated duodenal ulcer that requires management.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

Emergent (immediate plan required)

Urgent (plan required within 4 hours)

Routine

The patient requires urgent workup for their condition.

Assessment and Plan

Please provide your assessment and plan for this patient

This is a patient with long term NSAID use and smoking with chronic dyspepsia presenting with acute onset abdominal pain and peritoneal signs. CT scan was consistent with a perforated duodenal ulcer. Acute care surgery will be consulted for consideration of surgical duodenal repair with a Graham (omental) flap. The patient will also require H-pylori testing, antibiotic initiation, and initiation of proton pump inhibitors.

Lessons Learned:
- Perforation is a complication of peptic ulcer disease. The most common complication is upper GI tract hemorrhage.
- A perforated ulcer should be suspected if the patient presents with acute worsening of pain with peritoneal signs. In this case, a CT scan with IV contrast should be performed which often shows pneumoperitoneum and discontinuity in the duodenal wall or stomach with adjacent air locules.
- Otherwise, if an non-perforated ulcer is suspected, EGD or fluoroscopy are the appropriate diagnostic methods.

Socioeconomic Factors: Management of risk factors from a primary care standpoint can significantly reduce risk of ulcer formation and subsequent perforation. For example, patients who smoke should be provided with resources for smoking cessation and patients with chronic pain should be educated on dangers of chronic NSAID use. Patients with peptic ulcer disease should also be educated on signs of ulcer perforation. Studies have shown that patients who present earlier and undergo immediate management had better outcomes than those that presented more than 24 hours after symptom onset.

That's the end of the module! Once you've reviewed the video(s), you can click here for another case challenge.

Contributors:
Kevin Pierre, MD - Editor
Robbie Slater, MD - Supervising Editor
Bayar Batmunh, MS - Coordinator