Transcript 52-Year-Old Woman With Intractable Nausea and Vomiting

52-Years-Old Woman
With Intractable
Nausea and Vomiting
A 52-year-old woman (gravida 3,
para 3, abortus 0)
presented to the emergency
department with a recent
history of intractable nausea,
vomiting, and abdominal
pain
Three weeks before presentation,
she had started taking oral
contraceptives (OCPs), which were
prescribed to control
dysfunctional uterine bleeding
The bleeding was thought to be
secondary to a newly
discovered uterine fibroid.
The patient’s daily bleeding had
stopped completely 4 days
before admission
Her symptoms had begun 1 day
before admission, when she woke up
feeling nauseated and
could not stop vomiting.
She thought she had the flu and
postponed coming to the hospital
The patient described
lower quadrant abdominal pain and
several bloody, soft stools the day before
admission. She denied any fevers or
diarrhea. Her medical history was
unremarkable, and she
reported only osteoarthritis and a prior
tubal ligation
She denied taking any daily medications
except for the OCPs,
which she had also taken at the age of 19
years with no
problems. The patient had a clinically
relevant smoking
history, having smoked 1 to 2 packs per
day since the age
of 14 years. She drank wine socially
In the 3 months preceding her recent
uterine bleeding,
the patient had had no vaginal bleeding
or menstrual cycles.
Up until that time, she had been having
regular cycles
with normal flow.
She had also been having hot flashes for
about a year before admission
The patient had regularly
undergone Papanicolaou smears and
mammography, with
no abnormalities identified.
She had never undergone an
endometrial biopsy and had not yet
undergone a screening
colonoscopy
On presentation,
the patient was writhing in severe pain,
seemingly unable to find a comfortable
position.
Her abdominal examination was notable
for hypoactive bowel
sounds and tenderness, most prominent
in the left lower quadrant. Peritoneal
signs were absent
Her presentation
was markedly out of proportion with
the findings on
physical examination. Findings on the
remainder of the examination,
including the neurologic and
peripheral arterial examinations,
were unremarkable
Which one of the following is the most likely
etiology of this patient’s presentation?
• a. Diverticulitis
• b. Cerebellar infarction
• c. Acute mesenteric ischaemia
• d. Nephrolithiasis
• e. Ischemic colitis
The correct answer is
C
Diverticulitis is high in the differential diagnosis
of a patient with abdominal pain localizing to
the left lower quadrant.
However, the presence of bloody stools and the
absence of fever argue against this diagnosis.
Diverticulitis becomes
more prevalent with increasing age; however,
with the current obesity epidemic, this
demographic may include much younger
people
A cerebellar infarction should always be
considered in a patient with
cardiovascular risk factors, particularly
one presenting with nausea and vomiting.
However,
the lack of associated neurologic signs
and symptoms, as well as the presence of
bloody stools and abdominal tenderness,
argues strongly against the diagnosis in
this case
In a case series of 15 patients with missed
cerebellar infarctions, gastritis and
gastroenteritis were common alternative
diagnosis in those with symptoms of nausea
and vomiting.
Many of these patients had normal findings on
computed tomography (CT) of the head, which
is a highly insensitive study for
the detection of early posterior fossa ischemia
Acute mesenteric ischemia is the most
likely diagnosis, given the clinical context
in this case.
The patient had several immediate
risk factors for clot formation, including
her age, smoking
status, and recent initiation of OCPs.
Further, her symptoms
were disproportionate to her examination
findings
Nephrolithiasis, which is a reasonable
differential diagnosis given lower
quadrant writhing abdominal pain, is
often associated with nausea and
vomiting.
However, the presence of
abdominal tenderness on examination
and history of bloody
stooling make this diagnosis unlikely
This presentation has
many features consistent with ischemic
colitis, which is a
consequence of small-vessel
atherosclerosis and a transient
decrease in blood flow to the colon.
Ischemic colitis typically occurs in adults
older than 60 years and presents with
left-sided abdominal pain and bloody
stools
The history is typically more
protracted, and the pain less intense,
than would be seen with acute
mesenteric ischemia.
It is critical
to exclude acute mesenteric ischemia
first because it carries considerable
mortality, which can be affected by an
early invasive approach
The patient was given intravenous
hydration, began receiving
fentanyl patient-controlled
analgesia, and was given
intravenous antiemetic agents
Her laboratory examination revealed the
following:
leukocyte count, 27.6 × 10 /L (3.5-10.5 × 10 /L),
with a predominant neutrophilia;
hemoglobin, 12.5 g/dL
(12.0-15.5 g/dL);
and platelet count, 311 × 10 /L
(150-450 × 10 /L).
The electrolyte panel returned the
following results: sodium, 134 mEq/L
(135-145 mEq/L);
potassium, 3.4 mmol/L (3.6-4.8 mmol/L);
chloride, 102 mmol/L (100-108 mmol/L);
bicarbonate, 18 mEq/L (22-29 mEq/L);
creatinine, 0.5 mg/dL (0.7-1.2 mg/dL);
and blood urea nitrogen, 6
mg/dL (6-21 mg/dL).
Also noted was 1.4 mmol/L of lactate
(0.6-2.3 mmol/L). A panel of abdominal
markers revealed
the following: alkaline phosphatase, 71 U/L
(41-108 U/L);
aspartate aminotransferase, 31 U/L (8-43 U/L);
alanine aminotransferase, 12 U/L (7-45 U/L); lipase, 69 U/L
(10-73
U/L); and total bilirubin, 0.4 mg/dL (0.1-1.0
mg/dL).
Which one of the following is the most appropriate
next diagnostic test?
The correct answer is
c
In the setting of an abdominal emergency,
plain abdominal radiography is most useful for
diagnosing bowel
obstruction, pneumoperitoneum, and
occasionally ureteral
calculi.
However, with a high clinical suspicion for
bowel
ischemia and laboratory identification of low
bicarbonate
levels, plain radiography would not be the best
next test
The preclinical probability for
thrombosis in our patient
was high,
meaning that findings on
D-dimer assay would
not affect management
The best next test would be CT
angiography,
which could identify an occluded
vessel, would be better at
characterizing potentially ischemic or
necrotic
intestinal tissue, and might identify a
source for embolization
Abdominal ultrasonography with Doppler imaging
is a potentially useful study in this setting;
however,
it is not as sensitive as CT angiography would be.
Lactic
acid levels can be very useful in the diagnosis of
intestinal
ischemia but are not a perfect screening tool
Lactate has
been reported to have a sensitivity of
96% to 100%, with a
speciicity of only 38% to 42%. Normal
lactate levels may
be seen, especially early in
establishing or ruling out the
diagnosis of acute mesenteric
ischemia
Given the patient’s age,
smoking history, recent
initiation of OCPs, and
examination findings,
urgent CT angiography of the
chest, abdomen, and pelvis was
performed
An occlusive thrombus of the
celiac trunk was identified with
distal splenic arterial occlusions,
massive splenic infarcts,
and a wedge-shaped hepatic
infarct
A nonocclusive thrombus
in the superior mesenteric
artery was also present.
No bowel wall thickening, fat
stranding, or pneumatosis was
noted
On CT angiography, a small
(subcentimeter), mobile thrombus in the
ascending aorta was identified in an
area of an atherosclerotic plaque.
Scattered, mild plaques
were noted throughout the aorta.
An emergent consultation
was sought with vascular and general
surgery
Which one of the following is the most
appropriate next step in management of
this patient?
• a. Thrombolytic therapy.
• b. Surgical embolectomy.
• c. Emergent bowel resection.
• d. Invasive mesenteric angiography.
• e. Continuous heparin infusion and
serial abdominal examination.
The correct answer is
e
Thrombolytic therapy could be an
appropriate intervention for an acute
arterial thrombosis or embolism.
However, in our patient both the
recent history of menorrhagia and the
risk of dislodging the ascending aortic
thrombus preclude the use of
thrombolytic agents
surgical embolectomy and emergent
bowel resection would be
appropriate if peritoneal signs or a
major embolus in the absence of
peritoneal signs was present.
The presence of
peritoneal signs is thought to be a
surrogate of underlying bowel
infarction
Mesenteric revascularization, possibly
by embolectomy, should typically
precede bowel resection in an
effort to preserve potentially
viable intestinal segments and
spare resection of more bowel
than is necessary
Invasive mesenteric
angiography is the criterion
standard imaging test for
suspected acute
mesenteric
ischemia
Had this technique been used in our
patient,
a catheter could have been left in
place for continuous
infusion of papaverine, a
phosphodiesterase inhibitor.
Papaverine acts as a vasodilator and
can potentially help rescue
salvageable bowel
Because our patient did not
have clinical evidence of infarcted
bowel, major embolism, multiorgan
failure, or hemodynamic instability,
she
was initially managed conservatively
with a continuous
heparin infusion and careful clinical
monitoring
Transesophageal
echocardiography was
performed,
revealing no evidence of atrial
septal defects or intracardiac
thrombi
Early in the morning after admission,
the patient had an episode of dark,
red hematemesis and was
found to have voluntary guarding on
examination.
She
was taken emergently to the
operating room for an exploratory
laparotomy
During the course of back-to-back
operations, the patient underwent
resection of 129 cm of
jejunum and subsequently an
additional 62 cm of ileum.
The patient was left with
approximately 210 cm of viable
small bowel.
Given the case information up to this point,
which one
of the following is the least likely precipitant of
the patient’s condition?
• a. Smoking , O.C.Ps , perimenopausal state
alone.
• b. Thrombophilia.
• C. Occult malignancy.
• d. Mesenteric vasculitis.
• e. Median arcuate ligament variant.
The correct answer is
e
Evaluation of a patient with an
arterial clot should include
consideration of both vascular and
thrombotic etiologies.
The combination of smoking and
OCPs is well known to be associated
with arterial events in women older
than 35 years and could be a suitable
explanation by itself
however, other etiologies should
be considered.
Screening for thrombophilia,
especially measurement of
antiphospholipid antibodies,
should performed because the
diagnosis establishes a need for
indefinite anticoagulation
malignancy is always a consideration in an
older person with a substantial clot burden;
however, arterial events are
much less frequent than venous ones.
Mesenteric vasculitis
is typically a manifestation of a systemic
vasculitis, and
the mechanism of ischemia may include
luminal narrowing, thrombosis, or spontaneous
dissection
Median arcuate ligament variant occurs as
a result of a normal anatomic variant, in
which the celiac axis becomes indented.
A small
number of persons with this variant will
be clinically affected. This diagnosis would
not explain the presence of
thrombosis and typically evolves more
gradually
The patient tested negative for
thrombophilia;
however,
this testing was performed during the
acute phase and may be misleading.
The patient underwent uterine
ultrasonography, which revealed an
endometrial thickness less than 5
mm, and an endometrial biopsy was not
pursued
Follow up laboratory studies revealed a
resolved leukocytosis (leukocyte count, 7.4 ×
1000)
hemoglobin (13.3 g/dL), and marked
thrombocytosis (platelet count, 962 × 1000).
Which one of the following is necessary
to complete the medical management of
our patient?
• a. prophylactic splenectomy.
• b. vaccination for strept. Pneumoniae , hemophilus
influenzae B , neisseria meningitidis.
• c. initiation of long term TPN.
• d. Recommendation for indefinite anticoagulant ttt.
• e. initiation of progesterone only tablets.
The correct answer is
b
Most of the patient’s spleen was infarcted,
accounting for her marked thrombocytosis.
A small percentage of patients with infarcted
spleens develop an abscess, which may require
splenectomy, especially if multifocal in
nature.
However,
there is no role for routine, prophylactic
splenectomy
In the setting of a functional splenectomy,
prophylactic vaccinations for S pneumoniae, H
influenzae B, and N meningitidis are indicated.
The risk of post-splenectomy sepsis is
approximately 1% to 2% in adults, but the
mortality may exceed 50% if it does occur
Acute mesenteric ischemia, along with Crohn
disease, is a leading risk factor for short-bowel
syndrome.
Patients with more than a 50% reduction or
less than 200 cm of functional small bowel are
at risk of developing this syndrome of
malabsorption and malnutrition
Many patients
require long-term total parenteral
nutrition; however, on the
basis of the amount of bowel
removed, our patient was not
at high risk
If our patient had met criteria for
antiphospholipid syndrome, indefinite
anticoagulation would have been
indicated.
However, treatment for 3 to 6 months
with follow-up imaging would be an
appropriate recommendation at this time
In terms of the patient’s fibroid,
progesterone-only tablets
could be considered but are not
necessary.
Given that she
had a stable hemoglobin level, expectant
management would be a reasonable
approach.
Endometrial ablation or even hysterectomy
could be considered depending on her
subsequent clinical course
The patient was able to tolerate oral intake and was
bridged to a therapeutic international normalized
ratio with coumarin and heparin; uterine bleeding
did not recur.
Anticoagulation for 3 months was recommended, with
follow-up CT angiography before discontinuation of
therapy to evaluate both the aortic arch and
mesenteric thrombi
DISCUSSION
Arterial emboli are the most frequent
etiology of acute mesenteric ischemia,
followed by arterial thrombosis,
nonocclusive
disease, and rarely, venous thrombosis.
The former 2 conditions classically present abruptly,
whereas the latter 2 have a more gradual onset and
protracted course;
all are associated with a nonspecific set of symptoms.
A history of
postprandial abdominal pain, nausea, and weight loss
can help in differentiating a decomposition of a
long-standing problem from a new embolic or
thrombotic event
Clinical
history and imaging findings may help in
differentiating between
acute thrombosis and embolism.
However, as in our
case, this distinction can be difficult.
Regardless, all 4 etiologies
of acute mesenteric ischemia can progress to
bowel infarction, which may manifest
clinically as an acute abdomen, with a sepsistype picture.
Establishing the diagnosis
early, before the development of bowel
infarction, has been a major factor in reducing
mortality.
In a recent series of
77 patients with acute intestinal ischemia
managed surgically,
the 30-day mortality rate was 30.0% for
patients with arterial occlusive disease,
67.9% for those with nonocclusive disease,
and 10.5% for those with mesenteric venous
thrombosis.
Thus, establishing the etiology is useful in
assessing prognosis.
Arterial embolism may be suspected clinically
in the
setting of atrial fibrillation, myocardial
infarction, ventricular
aneurysm, aortic mural thrombi, and certain
valvular diseases.
Paradoxical emboli should be considered if
a patent foramen ovale is identified
The major risk factors for arterial thrombosis
include atherosclerosis, estrogen
replacement therapy, and hypercoagulability.
The distinction
is also important in that a diagnosis of acute
mesenteric thrombosis should prompt an
early invasive approach
because of the high in-hospital mortality
associated with this etiology.
Regardless of etiology, an early invasive
approach should be adopted in the
presence of hemodynamic instability or
peritoneal signs or if the clot completely
occludes the superior mesenteric artery
or resides in the superior
mesenteric artery above the origin of the
ileocolic artery
The pathogenesis of arterial
thrombosis is complex and often
involves an interaction among
atherosclerotic disease, rheology,
and thrombophilia, a concept
embodied in the Virchow triad
The high lipid content of advanced
atheromatous lesions is very thrombogenic,
largely because of a high
content of tissue factor. When exposed to the
circulating blood after plaque rupture,
tissue factor initiates the coagulation
cascade, which culminates in thrombin
generation.
Smoking is a known inducer of tissue factor
expression.
A link between oral contraception and
myocardial infarction
has been known since the 1960s. The RATIO
(Risk
of Arterial Thrombosis in Relation to Oral
Contraceptives)
study was a case-control study looking at 248
women with first myocardial infarction,
limited to those aged 18 through
49 years
Current OCP use was associated with a 2.0-fold
(95% confidence interval [CI], 1.5-2.8) increased
risk of myocardial infarction compared with nonusers.
In users of
OCPs, this risk increased to 13.6-fold (95% CI, 7.9-23.4) in
smokers, 17.4-fold (95% CI, 3.1-98.1) in patients with
diabetes,
and 24.7-fold (95% CI, 5.6-108.5) in patients with
hypercholesterolemia.
Oral contraceptives are similarly known
to be a risk factor for ischemic stroke and also synergize with
cardiovascular risk factors in that regard.
Convincing evidence for an association
between inherited thrombophilia and arterial
thrombosis is lacking.
The
notable exception to this is the
antiphospholipid syndrome,
in which arterial events are common, with
stroke being the initial manifestation in 13%
of patients.
However, environmental
factors may drastically augment the risk of
arterial
events in patients with inherited
thrombophilias. For example,
on the basis of a limited amount of data, Reny
et al found a 143-fold increased risk of
peripheral arterial occlusive disease in
smokers with the prothrombin G20210A
allelic variant, without increased risk in carriers
of factor V Leiden.
The factor V Leiden and methylene
tetrahydrofolate
reductase C677T genotype have been shown to
synergize
with OCP use in increasing risk of ischemic
stroke in younger patients.
Oral contraceptives are absolutely
contraindicated in
smokers older than 35 years, in patients with
diabetes who
have vascular complications, in patients with
uncontrolled
hypertension or hyperlipidemia, and in patients
with migraine
associated with neurologic deficit
The estrogen
burden of OCPs has decreased dramatically
since their introduction,
from 150 μg to the current 20 to 35 μg, and
progestins
have evolved to reduce the androgenic and
metabolic effects seen with first-generation
agents.
In women without
a frank contraindication who are concerned about the
risk of thrombosis, a product can be selected with
lower estrogen content.
Similarly, a third-generation progestin should be
used if there is concern for dyslipidemia and/or
metabolic control.
However, it is controversial whether use of second vs
third-generation OCPs affects clinical end points
This case demonstrates that
prescribing OCPs in perimenopausal
women, especially those with a
smoking history,
can have grave consequences, even
when just for a short time
Thank you