Abdominal Pain

1. Abdominal Pain Clinical Cases

2. PC • 62 yo male • Presents with epigastric + lower chest pain

3. HPC • The abdominal pain is similar to that of pancreatitis 5 years ago. • The chest discomfort is intermittent and occurs with deep inspiration, described as "pressure like". • The abdominal pain is sharp and burning in nature. • Onset 6 hrs ago • There are no other associated symptoms. The patient reports no radiation, nausea, vomiting, diarrhea or constipation, no SOB or sweating. • The onset of the symptoms was during rest and light activity. The pain is described as 5/10.

4. PMHx • Diabetes type 2 (DM 2), pancreatitis, hypertension (HTN), Meds • Pioglitazone, pentoxifylline, atenolol, triamterene and hydrochlorothiazide

5. Social Hx • No smoking, alcohol or drugs • No significant family history

6. Preliminary Dx thoughts? • Coronary artery disease/IHD (RF’s) • BiliaryDzPeptic ulcer Dz(PUD) GORD Gastritis/oesophagitis Pancreatitis AcutePneumonia and pleurisy (no cough/fever/chills…)Hepatitis due to NASH or one of the drugsIschaemic bowel Obstruction

7. Physical Exam • Obese male – NAD • Vital signs: T =38 RR =16 BP =153/79 • Resp: Clear to auscultation • CVS: S1S2. No added sounds • Abdomen: Soft, RUQ tenderness, no rebound, Murphy negative, +BS. • Legs: no oedema • No other significant findings

8. Ix • FBC, Electrolytes, Glucose, Serum amylase, Inflam. Markers LFTs, Urine analysis, Hepatitis Profile, • ECG, CXR, US • RESULTS: • Raised inflam markers • Total and direct bilirubin ↑ • AST, ALT slightly ↑ • GGT, ALP markedly ↑ • Negative for all heps • Cleared for ACS

9. U/S showed gallstones, obstructing cystic duct. Bile-ducts aren't dilated. • Cholelithiasis

10. MGMT • Cholecystectomy. Showed evidence of gallstones impacted in cystic duct – causative of acute cholecystitis • Antibiotics – Amoxy and Gentamicin IV

11. Notes…. • Charcot’s triad = fever, RUQ pain, jaundice = ascending cholangitis • Reynold’s Pentad = Charcots + hypotension + altered mental state = septic cholangitis

12. Case 2 • 47 yo female presents to ED • PC- colicky abdominal pain. The current episode of pain began several hours ago, following a fatty meaI. • The pain began slowly, and rose in intensity to a plateau over the course of several hours. • The patient reports several similar episodes after the last few weeks. • On physical examination, she is noted to have tenderness to deep palpation in the RUQ. The patient also reports that she is experiencing shoulder/back pain at a site she identifies near the right lower scapula, but no tenderness can be elicited during the back and shoulder examination.

13. Which of the following organs is the most likely source of this woman's pain? A. Appendix B. Diaphragm C. Esophagus D. Gallbladder E. Stomach • Which of the following techniques would be most appropriate to demonstrate the patient's most likely diagnosis? A. Colonoscopy B. CT scan of the abdomen C. Esophagoduodenoscopy D. MRI E. US • Following appropriate diagnostic studies, the patient is taken to the surgical suite. During the surgery, the surgeon inserts his fingers from right to left behind the hepatoduodenal ligament. As he does so, his fingers enter which of the following? A. Ampulla of Vater B. Common bile duct C. Epiploic foramen D. Greater peritoneal sac E. Portal vein

14. During the cholecystectomy, the surgeon ligates the cystic artery. This is typically a branch of which of the following? A. Gastroduodenal artery B. Left gastroepiploic artery C. Right gastroepiploic artery D. Right hepatic artery  E. Superior pancreaticoduodenal artery • Pathologic examination of the specimen removed by the surgeon demonstrates the presence of numerous yellow stones. These are most likely composed primarily of which of the following? A. Bilirubinate B. Calcium phosphate C. Cholesterol D. Cystine E. Struvite

15. Case 3 • A 64yo man with a history of coronary artery disease comes to the ED with the acute onset of severe, constant, lower abdominal pain and rectal bleeding. He reports that he previously has had several episodes of similar, but less severe pain. • About 12 hours after the onset of pain, the patient began passing copious bright red blood per rectum. He denies nausea, vomiting, or foreign traveI. No close friends/family are sick • Physical examination reveals a distressed man, who is afebrile, but tachypnoeic, with diffuse abdominal tenderness to palpation. Rectal examination is positive for blood. Lab studies reveal a metabolic acidosis with an elevated serum Iactate.

16. Which of the following is the most likely diagnosis? A. Colon carcinoma B. Infectious colitis C. Inflammatory bowel disease D. Ischemic colitis E. Necrotizing enterocolitis • The lactate produced from the anaerobic metabolism in the infarcted gut will likely be which of the following? A. Exhaled as a fruity odor B. Incorporated into glycogen in the liver C. Incorporated into myoglobin in muscle D. Incorporated into urea in the urine E. Secreted by the kidneys unchanged • If this patient's disease were drug-induced, which of the following agents would most likely be responsible? A. Acetaminophen B. Amiodarone C. Cocaine D. Dexamethasone E. Nitroglycerin

17. While the patient is in the emergency department, the pain becomes increasingly severe. Several hours after his initial examination, thepatient becomes febrile and is now exquisitely tender to palpation. He writhes in pain when the physician jostles the bed. Air is seen underthe diaphragm in an upright chest x-ray film. These new findings suggest which of the following? A. Abdominal aortic aneurysm  B. Bowel obstruction C. Cholecystitis D. Hypovolemia E. Perforation with peritonitis • Upon surgical exploration of the abdomen, the colon is dull and dusky from the mid transverse colon to the rectum. The patient has occluded which of the following vessels? A. Celiac trunk B. Cystic artery C. External iliac artery  D. Inferior mesenteric artery E. Superior mesenteric artery