April 2, 2012

The cryptic abdominal pain

I really love the thrill of evaluating the patient with abdominal pain of unknown origin. True abdominal pain is a symptom, not just a complaint and an underlying pathology should be sought. Emergency physicians have a critical role in diagnosing what can and should be treated and sending home everything else. They are the gatekeepers and must know uncommon diseases presenting as common symptoms.
I recently had an interesting case of abdominal pain which had valuable take home lessons for the EP, I would like to present it for you to share my learning points.
A 50y/o male who was treated three years ago for non-Hodgkin lymphoma and was cured. He now comes to the ED with two day history of sudden onset, aching pain in left lower quadrant. It was worse when he was lying on his left side. No fever/chills, nausea, diarrhea or other symptoms. Despite pain been able to eat and is not generally sick or affected by his pain.

Patient is worried that this might be his lymphoma coming back since at that time he had a similar diffuse central, upper abdominal pain going on for 5 weeks until he finally had his diagnosis.

On examination the patient has normal vital signs and is afebrile. Abdomen is non-distended, soft on palpation with localized pain about 5x5cm in left lower fossa. No muscle guarding. No palpable tumors. Lab tests all normal (WBC, CRP, hemoglobin, electrolytes, LFTs). A clever surgeon had a theory and asked for a CT abdomen which reveals a diagnostic image.

What is the diagnosis? (hint: look in LIF)

The radiologist notices "stranding of fat near colon descendens and nearby an enclosed capsule containing fat". Bull's eye for the surgeon: epicloic appendagitis it is indeed. Patient is sent home on NSAIDs to expect full recovery within 1-2 weeks.
Now this is certainly a rare condition but definitely worth knowing as we are working with abdominal pain all the time in the ED. The patient was indeed very sensitive in exactly that 5x5 area but unaffected otherwise. It was tempting to send him back home but it just didn't make sense, there had to be something explaining his pain. So in the future it will be on my ddx list of unexplained abdominal pain.

Another case of abdominal pain

Then there was another take home lesson from this particular patient. It turns out he some years earlier had a long and worrisome period of pain for 5 weeks until he screamed at the doctors to order a CT. And he was right... His epigastric/thoracal pain was at first diagnosed as 'gastritis' (the all too commonly used trashcan for unspecific symptoms!) and treated unsuccessfully with PPIs and later Tramadol. When the patient couldn't sleep any more and caught fever even he comes back and gets a CT which shows a 17x15x12cm big retroperitoneal monster tumor!

What are the take home lessons?

First of all, we need to suspect lymphoma to find lymphoma. The lymphomas are after all a relatively common disease (about 5% incidence), highly curable but presenting in many different ways. All medical textbooks describe unexplained abdominal/chest pain as one of the presenting symptoms so the lawyers will expect you to know that.

History and clinical examination are as always the cornerstone of diagnosis - nothing new here, just that they are all too commonly ignored. "B-symptoms" (fever, night sweats, weight loss), enlarged lymph nodes >2 weeks duration (be careful with unilaterally enlarged tonsil in children!) and if bone marrow is involved expect hematological symptoms (anemia, infections, bleeding...).

Use your ultrasound! As bedside ultrasound is becoming available in every emergency department there is no excuse of not making a quick look. If you know FAST you know how to localize the liver, spleen, aorta and surrounding area. Of course you are not expected to find deep enlarged lymph nodes but the above mentioned monster tumor would have been hard to miss.

LD/LDH is a cheap labtest worth considering, neither sensitive or specific but abnormal value should raise your eyebrows.

Any tips or thoughts from the readers?