52-Years-Old Woman With Intractable Nausea and Vomiting

1. 52-Years-Old Woman With Intractable Nausea and Vomiting

2. A 52-year-old woman (gravida 3, para 3, abortus 0) presented to the emergency department with a recenthistory of intractable nausea, vomiting, and abdominalpain

3. Three weeks before presentation, she had started taking oral contraceptives (OCPs), which were prescribed to control dysfunctional uterine bleeding

4. The bleeding was thought to be secondary to a newly discovered uterine fibroid. The patient’s daily bleeding had stopped completely 4 days before admission

5. Her symptoms had begun 1 day before admission, when she woke up feeling nauseated and could not stop vomiting. She thought she had the flu and postponed coming to the hospital

6. The patient described lower quadrant abdominal pain and several bloody, soft stools the day before admission. She denied any fevers or diarrhea. Her medical history was unremarkable, and she reported only osteoarthritis and a prior tubal ligation

7. She denied taking any daily medications except for the OCPs, which she had also taken at the age of 19 years with no problems. The patient had a clinically relevant smoking history, having smoked 1 to 2 packs per day since the age of 14 years. She drank wine socially

8. In the 3 months preceding her recent uterine bleeding, the patient had had no vaginal bleeding or menstrual cycles.Up until that time, she had been having regular cycles with normal flow. She had also been having hot flashes for about a year before admission

9. The patient had regularly undergone Papanicolaou smears and mammography, with no abnormalities identified.She had never undergone an endometrial biopsy and had not yet undergone a screening colonoscopy

10. On presentation, the patient was writhing in severe pain, seemingly unable to find a comfortable position. Her abdominal examination was notable for hypoactive bowel sounds and tenderness, most prominent in the left lower quadrant. Peritoneal signs were absent

11. Her presentation was markedly out of proportion with the findings on physical examination. Findings on the remainder of the examination, including the neurologic and peripheral arterial examinations, were unremarkable

12. Which one of the following is the most likely etiology of this patient’s presentation? • a. Diverticulitis • b. Cerebellar infarction • c. Acute mesenteric ischaemia • d. Nephrolithiasis • e. Ischemic colitis

13. The correct answer is C

14. Diverticulitis is high in the differential diagnosis of a patient with abdominal pain localizing to the left lower quadrant.However, the presence of bloody stools and the absence of fever argue against this diagnosis. Diverticulitis becomes more prevalent with increasing age; however, with the current obesity epidemic, this demographic may include much younger people

15. A cerebellar infarction should always beconsidered in a patient with cardiovascular risk factors, particularly one presenting with nausea and vomiting. However,the lack of associated neurologic signs and symptoms, as well as the presence of bloody stools and abdominal tenderness, argues strongly against the diagnosis in this case

16. In a case series of 15 patients with missed cerebellar infarctions, gastritis and gastroenteritis were common alternative diagnosis in those with symptoms of nausea and vomiting.Many of these patients had normal findings on computed tomography (CT) of the head, which is a highly insensitive study for the detection of early posterior fossa ischemia

17. Acute mesenteric ischemia is the most likely diagnosis, given the clinical context in this case. The patient had several immediate risk factors for clot formation, including her age, smokingstatus, and recent initiation of OCPs. Further, her symptoms were disproportionate to her examination findings

18. Nephrolithiasis, which is a reasonable differential diagnosis given lower quadrant writhing abdominal pain, is often associated with nausea and vomiting. However, the presence of abdominal tenderness on examination and history of bloody stooling make this diagnosis unlikely

19. This presentation has many features consistent with ischemic colitis, which is a consequence of small-vessel atherosclerosis and a transient decrease in blood flow to the colon. Ischemic colitis typically occurs in adults older than 60 years and presents with left-sided abdominal pain and bloody stools

20. The history is typically more protracted, and the pain less intense, than would be seen with acute mesenteric ischemia. It is critical to exclude acute mesenteric ischemia first because it carries considerable mortality, which can be affected by an early invasive approach

21. The patient was given intravenous hydration, began receiving fentanyl patient-controlled analgesia, and was given intravenous antiemetic agents

22. Her laboratory examination revealed the following: leukocyte count, 27.6 × 10 /L (3.5-10.5 × 10 /L), with a predominant neutrophilia; hemoglobin, 12.5 g/dL (12.0-15.5 g/dL); and platelet count, 311 × 10 /L (150-450 × 10 /L).

23. The electrolyte panel returned the following results: sodium, 134 mEq/L (135-145 mEq/L); potassium, 3.4 mmol/L (3.6-4.8 mmol/L); chloride, 102 mmol/L (100-108 mmol/L); bicarbonate, 18 mEq/L (22-29 mEq/L); creatinine, 0.5 mg/dL (0.7-1.2 mg/dL); and blood urea nitrogen, 6 mg/dL (6-21 mg/dL).

24. Also noted was 1.4 mmol/L of lactate (0.6-2.3 mmol/L). A panel of abdominal markers revealed the following: alkaline phosphatase, 71 U/L (41-108 U/L); aspartate aminotransferase, 31 U/L (8-43 U/L); alanine ami-notransferase, 12 U/L (7-45 U/L); lipase, 69 U/L (10-73 U/L); and total bilirubin, 0.4 mg/dL (0.1-1.0 mg/dL).

25. Which one of the following is the most appropriate next diagnostic test?

26. The correct answer is c

27. In the setting of an abdominal emergency, plain abdominal radiography is most useful for diagnosing bowel obstruction, pneumoperitoneum, and occasionally ureteral calculi. However, with a high clinical suspicion for bowel ischemia and laboratory identification of low bicarbonate levels, plain radiography would not be the best next test

28. The preclinical probability for thrombosis in our patient was high, meaning that findings on D-dimer assay would not affect management

29. The best next test would be CT angiography, which could identify an occluded vessel, would be better at characterizing potentially ischemic or necrotic intestinal tissue, and might identify a source for embolization

30. Abdominal ultrasonography with Doppler imaging is a potentially useful study in this setting; however, it is not as sensitive as CT angiography would be.Lactic acid levels can be very useful in the diagnosis of intestinal ischemia but are not a perfect screening tool

31. Lactate has been reported to have a sensitivity of 96% to 100%, with a speciicity of only 38% to 42%. Normal lactate levels may be seen, especially early in establishing or ruling out the diagnosis of acute mesenteric ischemia

32. Given the patient’s age, smoking history, recent initiation of OCPs, and examination findings, urgent CT angiography of the chest, abdomen, and pelvis was performed

33. An occlusive thrombus of the celiac trunk was identified with distal splenic arterial occlusions, massive splenic infarcts, and a wedge-shaped hepatic infarct

34. A nonocclusive thrombus in the superior mesenteric artery was also present. No bowel wall thickening, fat stranding, or pneumatosis was noted

35. On CT angiography, a small (subcentimeter), mobile thrombus in the ascending aorta was identified in an area of an atherosclerotic plaque. Scattered, mild plaques were noted throughout the aorta. An emergent consultation was sought with vascular and general surgery

36. Which one of the following is the most appropriate next step in management of this patient? • a. Thrombolytic therapy. • b. Surgical embolectomy. • c. Emergent bowel resection. • d. Invasive mesenteric angiography. • e. Continuous heparin infusion and serial abdominal examination.

37. The correct answer is e

38. Thrombolytic therapy could be an appropriate intervention for an acute arterial thrombosis or embolism. However, in our patient both the recent history of menorrhagia and the risk of dislodging the ascending aortic thrombus preclude the use of thrombolytic agents

39. surgical embolectomy and emergent bowel resection would be appropriate if peritoneal signs or a major embolus in the absence of peritoneal signs was present. The presence of peritoneal signs is thought to be a surrogate of underlying bowel infarction

40. Mesenteric revascularization, possibly by embolectomy, should typically precede bowel resection in an effort to preserve potentially viable intestinal segments and spare resection of more bowel than is necessary

41. Invasive mesenteric angiography is the criterion standard imaging test for suspected acute mesenteric ischemia

42. Had this technique been used in our patient, a catheter could have been left in place for continuous infusion of papaverine, a phosphodiesterase inhibitor.Papaverine acts as a vasodilator and can potentially help rescue salvageable bowel

43. Because our patient did not have clinical evidence of infarcted bowel, major embolism, multiorgan failure, or hemodynamic instability, she was initially managed conservatively with a continuous heparin infusion and careful clinical monitoring

44. Transesophageal echocardiography was performed, revealing no evidence of atrial septal defects or intracardiac thrombi

45. Early in the morning after admission, the patient had an episode of dark, red hematemesis and was found to have voluntary guarding on examination. She was taken emergently to the operating room for an exploratory laparotomy

46. During the course of back-to-back operations, the patient underwent resection of 129 cm of jejunum and subsequently an additional 62 cm of ileum. The patient was left with approximately 210 cm of viablesmall bowel.

47. Given the case information up to this point, which one of the following is the least likely precipitant of the patient’s condition? • a. Smoking , O.C.Ps , perimenopausal state alone. • b. Thrombophilia. • C. Occult malignancy. • d. Mesenteric vasculitis. • e. Median arcuate ligament variant.

48. The correct answer is e

49. Evaluation of a patient with an arterial clot should include consideration of both vascular and thrombotic etiologies. The combination of smoking and OCPs is well known to be associated with arterial events in women older than 35 years and could be a suitable explanation by itself

50. however, other etiologies should be considered. Screening for thrombophilia, especially measurement of antiphospholipid antibodies, should performed because the diagnosis establishes a need for indefinite anticoagulation