Transcript Abdominal Pain – Multiple Differentials

Abdominal Pain – Multiple
Differentials
NP Virtual Rounds
February 10, 2009
History of Presenting Illness
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44 y/o female with c/o 12 day hx of
progressive abdominal pain
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S: sudden onset of abd pain 12 d ago following a spicy meal;
pain persistent and progressive, often worse after meals & at
night, started LRQ now epigastric & URQ, no N, V, or anorexia,
hemoptysis, no HA, no stiff neck, no ear pain/tinnitus, no vision
changes, indigestion, BMs normal w/ LBM yesterday, no urinary
symptoms, no problems w/ menses
Presented to clinic this am d/t intense, burning pain now at
epigastric, kept her awake through the night, travels upper R to
L w/ fever, ++ diaphoresis, alternating chills & hot flushes, no
rigors, pt wonders if has food poisoning. Rates pain currently as
intense
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Past Medical History
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Hysterectomy d/t fibroids & endometriosis, I
ovary removed – no pregnancies, no risk of
ectopic pregnancy
 No other surgeries, hx of serious illness,
trauma
 Partial excision of intramural fibroid
 No hx of IBS, GERD, no bowel disease –
crohn’s, colitis, no hx of gallbladder disease,
or diverticulitis
Other History
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No medications
 No allergies
 N/S, no ETOH, no recreational
drugs/OTC/herbals/home remedies
 Nothing taken to deal with current illness
 Social hx: lives alone on a boat, works at
Hollycock; active and healthy, no recent travel
out of the country
Physical Exam
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Thin, pale, diaphoretic woman, looking less than stated age
Alert, oriented, able to give good history – no recent URI/cold
VS: T 38.1, BP 106/62, HRR 70, RR 20
Urine dip: small WBC, neg nitrates, pos protein, trace blood
HEENT: TM – slightly red, serous fluid? No lymphadenopathy,
neg Kernig sign, neg Brudzinski sign
Resp: CTA, no CVA tenderness
CVS: S1 S2, no S3, S4, no murmurs/bruits
Abd: LKKS neg, discomfort over epigastric area w/ palpation,
pos rebound tenderness & guarding RLQ otherwise normal, neg
McBurney & psoas signs
Differential Diagnoses
 ?Acute
appendicitis
 Gastroenteritis
 Divertulitis
 GERD
 Biliary colic
 Pyelonephritis
Plan
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Need diagnostic work up
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Labs: CBC, renal fx, LFTs, bilirubin, amylase, h.
pylori
CT abd to r/o appendicitis (good standard)
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Consult w/ ER
 Transport via ferry accompanied by friend
 Further assessment: elicit better info on
pattern of pain i.e. colicky
 Other tests? Yersinia enterocolitica Serology, US,
Barium enema
Diagnosis & Management
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Initial ER temp 38.7 slightly elevated WBC w/
L differential w/ neuts 8.2, mildly hypoatremic
@ 130, U/A unremarkable w. significant RLQ
guarding & rebound tenderness, pain colicky,
RUQ Sx w/ no abdominal findings
 CT scan = Mesenteric lymphadenitis w/ +
mesenteric lymph nodes, normal appendix
 Incidential finding 2 cm cyst R ovary & 1.3
hyperattenuating lesion post aspect R lobe of
liver
 Admitted for observation & rehydration
Follow Up
post discharge – resolution of all
her symptoms
 U/S of liver to ensure lesion stability
 What is mesenteric lymphadenitis:
 F/u
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Mesenteric lymphadenitis is an inflammation of the
lymph nodes on the wall of the mesentery
Mesenteric lymphadenitis usually follow viral
infection with the common cold, or with infection by
Yersinia enterocolitica, Pseudo tuberculosis,
Streptococcus viridansor Campylobacter jejuni
Mesenteric Lymphadenitis
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CAUSE:
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The bugs gain access to the wall of the intestine, and invade
the lymph nodes on the covering of the intestines called the
mesentery.
The small intestine is frequently more involved, but the large
intestines or colon may also be involved.
The lymph nodes become enlarged due to inflammatory
process induced by the micro-organisms.
The inflammatory process, coupled with the stretch effect on
the wall of the mesentery by the enlarged lymph node cause
pain.
Pus may form in severe cases and spread to cause
disseminated infection.
Most times though, the infection resolves on it own without
the need to do anything.
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Mesenteric Lymphadenitis
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The signs and symptoms of mesenteric lymphadenitis are very similar
to those caused by appendicitis. They can however be differentiated
from those of appendicitis by some subtle differences.
Abdominal Pain. This is often located in the right lower abdomen or
right iliac fossa. It is a colicky abdominal pain which just resolves
momentarily without any intervention.
Preceding Cold or Sore Throat. One thing in the history that gives
away the diagnosis of mesenteric lymphadenitis is that of the
presence of common cold or sore throat in the days or week before
the onset of abdominal pain.
Fever. There may be an associated fever, running up to 38.5 degrees
centigrade.
Vomiting. Patient may vomit. If they vomited before the onset of
pain, appendicitis is most unlikely.
Diarrhoea. There may be episodes of loose stools, especially where
Yersinia infection is involved. Appendicitis could also cause diarrhoea.
Anorexia. Usually, with mesenteric lymphadenitis, patients are still
able to eat and drink. If a patient complains of abdominal pain, and
appetite remains good, it is most unlikely he or she has appendicitis.