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

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with diffuse abdominal pain.
  2. Review the DDx considerations in a patient with diffuse abdominal pain.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with diffuse abdominal pain.


Physical Exam


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

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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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