UnFiNiShEd CaSe – CoMe BaCk LaTeR

History of Present Illness:

A man in his mid-60’s with ESRD, dementia and h/o SBO presents to the hospital with severe generalized abdominal pain that started during dialysis and was associated with vomiting but no fever, diarrhea or other complaints.  He is a poor historian.

Vital Signs & Physical Exam:

Vital signs are normal except for somewhat elevated blood pressure

Physical exam is notable for a patient who is agitated and yelling in pain and threatening to walkout.  He later pulled out his IV and tried to leave

Initial Diagnostic Testing:

  • CBC: normal except for WBC 10.5 (baseline for him ~5.0) and Hb 10.5 (his baseline)
  • Chem-7: normal except for bicarb 22 (baseline 28 after dialysis) but anion gap of 21
  • Imaging: see plain film below and scout from the CT done hours later after the patient was finally calm enough for CT to take him hours later.

Why is it wise to do a plain film in a patient with excruciating abdominal pain, especially if they are confused?

  • A) look for free air
  • B) look for volvulus or mesenteric ischemia
  • C) look for SBO
  • D) minimize radiation exposure

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

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ANSWER:

  • A) look for free air – good thought, but patients with a perforation don’t usually act like this
  • B) look for volvulus – if a patient is screaming with excruciating abdominal pain it is probably drama but consider that they may have ischemic bowel.  Sudden bowel ischemia from either a volvulus or mesenteric ischemia can cause people to act crazy.  They may develop an agitated delirium that makes you wonder if they are a psych patient.  Before you decide they are, rule out bowel ischemia.  Plain films are faster and if they show a cecal volvulus you should call the surgeon before CT to minimize the chance of a bad outcome.  Mesenteric ischemia will almost always need a CT, but findings on plain film may push you to get the CT faster.  You cannot put these patients on the back burner.
  • C) look for SBO – for this you will usually need a CT though plain films may give you an answer sooner and get patients who will need surgery to the OR sooner.  Also, if there is low suspicion but you feel you need some imaging for SBO, plain films are quicker and have less radiation than CT.  Sensitivity is ~80%, and probably even higher if you call a gasless abdomen positive.
  • D) minimize radiation exposure – a consideration in younger patients or with low level of suspicion, but not for this patient.

CT cuts below showing pneumatosis in dilated small bowel (white arrowhead near lateral spinous process) and portal venous gas in the liver

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CASE CONCLUSION: became progressively more tachycardic and kept vomiting despite fluids and huge doses of pain meds and antiemetics. lactic acid was 6.3.  CT showed pneumatosis and portal gas, both excessive.  Patient went to the OR.  The physician had to push nurses to give adequate doses of pain meds to get the patient to CT.  Removed 65% of small intestine.  Fortunately had not perforated.  Survived surgery.

CASE LESSONS: a borderline WBC or bicarb usually aren’t big red flags, but they can be, especially if they are very different from a known baseline value