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I had read a different article recently talking about the AGAs recommendation change regarding uncomplicated diverticulitis; here’s another one from ACEP Now citing similar data. Perhaps another condition we can stop writing unnecessary antibiotics for. Do keep in mind this is for UNCOMPLICATED cases.
I had a patient in her 30s that presented with 1 day hx of N/V and diffuse abdominal pain that was most severe in her epigastric and LUQ and radiated to her back. She had PO intolerance since the pain started the night before. Past medical hx was significant for R nephrectomy that she states is because her “kidney wasn’t working right”. Pt says that this pain feels just like the pain she had from that kidney.
PE: VSS, afebrile. She is curled in the fetal position and yells anywhere you touch on her abdomen but states that the worst pain is when I press her epigastrum and LUQ. She has a large RUQ scar from her nephrectomy. No CVA ttp, negative murphy sign.
At this time my differential included pancreatitis vs PUD vs gastritis vs pyelonephritis
Labs come back with lipase wnl, no WBC, UA with a lot of epithelial cells and a few WBC. Acute abdominal series xray is wnl
I reassess patient after dilaudid and zofran and she states nausea has resolved but still has severe epigastric/LUQ pain. On reexamination the rest of the abdomen is nontender. The amount of pain she is experiencing in her epigastrum/LUQ concerns me and its not pancreatitis based on the lipase so I order a CT abd/pelvis and I put in the ordering comments “diffuse abdominal pain most severe in epigastric and LUQ”.
The radiologist walks over to the department to tell me that the patient has appendicitis and her appendix which is thickened and with fat stranding is in the mid right abdomen instead of RLQ hence the atypical location of her pain. My assumption is that the reason her appendix is so high is from scar tissue secondary to her transabdominal nephrectomy.
I post this to remind everyone that while the RLQ is the most specific place to have pain from appendicitis, the pain can be anywhere (previous abdominal surgery (in this case), retrocecal/pregnancy, etc).
Interesting case from a couple weeks ago.
20ish yo white male, no significant past medical diagnoses. Overweight. Family history of gallbladder disease. No OTC or Rx medications. Patient smokes, does not drink, and has used IV drugs in the past.
Here in the ER due to RUQ abdominal pain for one week, was coming and going and is now constant. On further questioning, admits that his mom made him come because of her history of gallstones and cholecystectomy. On exam patient has jaundiced sclera and urine on table is dark brown, pain in right upper quadrant of abdomen is exquisite. States he has been vomiting especially after eating and all food makes him sick. No documented fevers, but feeling chills.
Urine: Large bilirubin, otherwise normal
Pertinent blood: WBC 8.4, Hgb 14.2, Plt 430. Alk Phos 140, AST 734, ALT 1417, Total Bili 9.5. Lipase 22. Tylenol neg.
Didn’t expect this guys ‘acute chole’ to cause liver failure. Either way, he was getting further imaging to find out more. No ultrasound coverage at 5am so CT for now, then ultrasound at 7am. Added tox screens and hepatitis panel at this time.
CT abdomen/pelvis with contrast: “Markedly thickened/edematous wall of the gallbladder indicating cholecystitis. No calcified stone visualized. Additional imaging maybe obtained with ultrasound.” Also, normal liver.
The results of the ultrasound showed a “nondistended gallbladder with marked wall thickening, edema and a positive sonographic Murphy sign. Given lack of clear visualization of the posterior wall, highly worrisome for complicated cholecystitis, possibly gangrenous or with a focal posterior perforation.” Normal liver and mildly dilated bile duct.
Now with labs showing liver failure and two forms of imaging showing acute cholecystitis, it had to be. Admitted to the general surgery team though the ‘acalculous cholecystitis’ with liver failure was enough to peak my interest in follow-up.
Hepatitis panel comes back later same day showing reactivity for Hep C. Discharge 5 days later, no surgery, no acute interventions, with down-trending liver function panel and follow-up with the GI clinic.
While most commonly associated with cholecystitis, a quick literature search reveals multiple reasons besides cholecystitis to have gallbladder wall thickening… congestive heart failure (right sided), gallbladder carcinoma, adenomyomatosis (chronic gallbladder inflammation or degeneration), renal failure, pancreatitis, cirrhosis and other forms of liver failure.
Case #2:
30 yo F h/o morbid obesity and DM2 not well controlled on insulin and metformin presents after high speed MVA vs pole. 5 month old baby in back carseat sent the the Ped’s ED, unharmed. EMS called, prolonged extrication about 30 min, vitals en route stable, BP 120/76 and HR 96 just PTA (hmm?). No IVs established, axox3, talking, calm and cooperative.
On exam, breath sounds normal, seat belt sign obvious on lower abdomen with mild LUQ abdominal tenderness on exam, main c/o left thigh pain. Appears twisted but unsure if broken. Patient is morbidly obese, probably 350-400 lbs, which causes some problems next: placed on the monitor and HR 130, check pulses and does have pulses in distal extremities though weak, BP unable to get multiple times, then manual BP unable to obtain. Ask nurse why no BP, states “cuff not big enough to work properly,” also trying on leg.
IV placed in right AC no problem, placed NS on pressure bag. HR during xrays comes down from 130–>115.
CXR done nothing obvious, PXR done, again nothing obvious and left femur show proximal 3rd shaft fx, traction splint placed by intern, FAST scan neg in cardiac window, but very positive in pelvic window as well and slightly positive in RUQ and LUQ. Level 1 called after FAST and finally a BP obtained 80/40 as trauma walks in the door!!! Patient no longer with palpable peripheral pulses, good central pulses, a&ox3.
Ever feel like an idiot…just watched this lady with HR 130 and BP 80/40 for 18 minutes prior to level 1 trauma call!
Blood, central line, another peripheral IV. Trauma dawdled a little in ED more than should have, repeated the very positive FAST scan, though we did resuscitate her with blood and fluids, central line, trauma attempted a-line (apparently they didn’t trust the very low BP either) and finally went to CT scanner (another 25 min) and thought to have SMV avulsion (yikes) prior to taking her to the OR.
Diagnosis: avulsion of superior mesenteric artery (even worse). left femur fracture.
Patient spent more than one month in the SICU, never extubated, multiple loops of bowel resected for necrosis and never closed her abdomen, family decided to withdraw care after she continued to go downhill and quality of life would have been an issue.
Let me point out the obvious, I should have called a level 1 earlier. 10 min earlier when had HR in 130s and unable to obtain BP x 2 would have been enough. Unsure if her outcome would have been different, but sure makes me wonder.
Often times it is hard to get a BP on a morbidly obese person, esp when have peripheral pulses and axox3, but it is much better to be safe than sorry, call the level 1 when in doubt. Better for the patient’s sake to feel like an idiot earlier than to feel like an idiot later in the game.
The other thing is, we had her packaged for the OR when trauma arrived, peripheral IV and blood obtained, 1L fluids, HR 110, CXR, PXR and femur, traction splint to femur, FAST done and very positive. Should have gone straight to the OR as soon as trauma arrived. Trauma fellow wanted CT scan and further resuscitation (why try an a-line?) which took time.
Feedback and comments appreciated.