Acute Abdominal Pain: When the Whole Is Greater Than the Sum of Its Parts

Excerpt

A 71-year-old man with a history of intermittent chronic abdominal pain was evaluated in the emergency department with a 2-day history of constant, severe, left upper quadrant pain. He had been assessed in the emergency department the previous day but returned when his abdominal pain did not improve. He was afebrile with a pulse rate of 92/min, a respiratory rate of 20/min, a blood pressure of 143/68 mmHg, and a peripheral oxygen saturation of 90% while receiving oxygen at a rate of 7 l/min via nasal cannula. Auscultation of his lungs revealed crackles at both lung bases, with an otherwise normal pulmonary examination; there were no signs of consolidation or of increased dullness on percussion. Cardiovascular examination was normal, except for the presence of mild elevation of jugular venous pressure and moderate pitting edema in both ankles. Abdominal examination revealed a generally soft abdomen but with moderate tenderness on deep palpation in the left upper quadrant. There was no rebound tenderness, distension, palpable mass, shifting dullness, or hepato-splenomegaly, and bowel sounds were present and normal. Laboratory test results showed serum concentrations of sodium 130 mmol/L (137–145 mmol/L), potassium 5.2 mmol/L (3.4–4.8 mmol/L), and creatinine 1.22 mg/dL (0.66–1.25 mg/dL; baseline 0.6 mg/dL). The white blood cell count was 6.6 K/mm³ (4-10.6 K/mm³), hemoglobin 15.9 g/dL (14.5–17.7 g/dL), red blood cell count 8.39 × 10⁶/mm³ (4.64–6 M/mm³), hematocrit 54.7% (42–53%), mean corpuscular volume of 65 fl (81–98 fl), and platelet count 53 K/mm³ (150–400 K/mm³). Serum concentration of lipase was 125 U/L (23–300 U/L), but serum amylase concentration was not measured. Liver function tests were variably abnormal with serum concentrations of AST 82 U/L (17–59 U/L), ALT 178 U/L (21–72U/L), alkaline phosphatase 76 U/L (38–126 U/L), total bilirubin of 1.2 mg/dL (0.2–1.3 mg/dL), and albumin 2.9 g/dL (3.5–5 g/dL). INR was 1.4 (1.0–1.2). Brain natriuretic peptide (BNP) concentration was markedly elevated at 8800 pg/mL (nl < 125 pg/ml). Urinalysis revealed 2 RBC and 1 WBC, but was negative for leukocyte esterase and nitrites. An initial computerized tomographic (CT) scan of the abdomen and pelvis obtained in the emergency department showed non-specific thickening of the walls of the gastric antrum and proximal duodenum and small amounts of peri-pancreatic fluid (Fig. 1a): Liver contours were nodular with hypertrophy of the caudate lobe (not shown). No gallstones or ductal dilatations were apparent. An initial clinical diagnosis was made of heart failure in a patient with probable cirrhosis. A portable abdominal film on the day of admission showed a normal bowel gas pattern. Chest X-ray showed chronic diffuse interstitial opacities without consolidation or pleural effusion. The medical history also included thalassemia trait, dementia, diabetes mellitus type II, opiate dependence, thrombocytopenia (probably due to hypersplenism from portal hypertension due to cirrhosis), chronic obstructive pulmonary disease, with secondary polycythemia requiring phlebotomies in the remote past. His home medications included albuterol, budesonide/formoterol, tiotropium, aspirin, furosemide, potassium chloride, lisinopril, metformin, naproxen, and ranitidine.

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