A 65 year-old male with a past medical history of hypertension, hyperlipidemia, peripheral vascular disease, diverticulosis, and paroxysmal atrial fibrillation (only on aspirin due to a spontaneous subarachnoid hemorrhage 10 years ago) presents to the emergency department complaining of diffuse and band-like abdominal pain for the past hour. It started about 30 minutes after eating dinner. He became nauseous and described pain as 8/10. It occurred once prior about one month ago. He has not taken any medications prior to arrival. He had one episode of non-bloody, non-bilious emesis that was largely his dinner. He denies fever, chest pain, shortness of breath, diarrhea, constipation, melena, hematochezia, dysuria, hematuria, medication changes, or unusual ingestions.
Vital Signs:
HR: 130, RR: 22, BP: 98/62, O2: 99% on RA. Afebrile
PSH:
ILR implanted, Hemicolectomy 2/2 Diverticulitis flare 5 years ago
Social:
1-2 glasses wine/week
Previously a 1/2 PPD smoker but quit 10 years ago for a total of 30 Pack-years
No illicit drugs
Meds:
HCTZ-Lisinopril, ASA, Metoprolol, Lipitor
Physical Exam
General: Uncomfortable appearing, non-toxic, mild distress
Neuro: AxO x 3; no focal deficits
HEENT: Dry mucous membranes
CV: A-Fib at 130 bpm, no edema, mild chronic stasis changes to bilateral lower extremity
Lungs: Clear to auscultation, no wheezes/crackles/rhonchi/rales
Abd: Soft with mild distension; he cannot localize pain but is voluntary guarding; pain out of proportion is apparent. Hyperactive bowel sounds in all 4 quadrants. Previous surgical scar well-healed in the left lower quadrant. No hemorrhoids. Neg Stool Occult
GU: Within normal limits
Skin/Ext: Warm extremities and soft compartments, Pulses 2+ in upper extremities and 1+ in lower extremities
Differential diagnosis:
Mesenteric ischemia, gastroenteritis, colitis, obstruction, cholecystitis, PUD, perforated viscous, AAA, diverticulitis, etc.
Take Away #1 - Categories of Mesenteric Ischemia:
1) Arterial Emboli
a) Typically, from AFIB or Endocarditis
b) 50% of cases
2) Arterial Thrombus
a) Stenosis --> Angina --> CAD of the gut
b) ~ 20-30% of cases
3) Non-occlusive
a) i.e hypoperfusion 2/2 CHF, hypotension, sepsis, post-prandial pain due to exercising the gut, etc.
b) ~ 15-25%
4) Mesenteric Venous Thrombosis
a) 2/2 hypercoaguable state or previous inflammation in abd
b) ~ 10%
Take Away #2 - Have a low threshold to image elderly with abdominal pain --> This population has an approximate 10% mortality from underlying cause.
CT Angio of Abd with venous phase included --> Superior mesenteric artery is the most common, then inferior mesenteric artery, then the celiac artery
CT findings include bowel wall thickening, ascites, mesenteric edema, pneumatosis intestinalis (late), and perforation (late)
Take Away #3 - Work-up and Treatment
Basic labs but include troponin, lactic acid, T&S, coags
EKG, IVF, NPO
Imaging including CXR to rule out perforation, CT Angio abd/pelvis
Antibiotics
Pain control
Heparin gtt
Vascular and Surgical Consult
BE MINDFUL of VASOPRESSORS --> many pressors lead to splanchnic vasoconstriction. But if the patient is crashing in front of you then you obviously need them.
Matthew Tanzi, MD is a current third year resident at Stony Brook Emergency Medicine. He can be found on Twitter @mtanzi2791.
References:
Lo B (2020). Lower gastrointestinal bleeding. Tintinalli J.E., & Ma O, & Yealy D.M., & Meckler G.D., & Stapczynski J, & Cline D.M., & Thomas S.H.(Eds.), Tintinalli's Emergency Medicine: A Comprehensive Study Guide, 9e. McGraw-Hill.
Edited by Bassam Zahid, MD