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?

A case of bradycardia - biliary disease or acute coronary syndrome?

A middle-aged man comes to the ED with one day history of severe pain in the upper abdomen. He is feeling increasingly uncomfortable and has nausea without vomiting. He appreciates his pain as VAS 7-8. On physical examination he is tender on palpation in the epigastrium, physical examination is otherwise completely normal. You get an ECG with no signs of ischemia but you observe sinus bradycardia at 37 beats per minute.

The lab results unfortunately return a hemolyzed Troponin-T but the LFT (liver functional tests) show ALP=3.2, GGT=8.8, ALT=1.4 and AST=2.3 (slightly elevated, suggesting cholestasis). Could the pain have a cardiac etiology?

Inferior MI and diseases of the upper gastrointestinal tract (gallbladder, stomach/esophagus especially) can present in very similar ways. Besides epigastric pain, patients commonly describe bloating and reflux-like symptoms due to vagal stimulation and gastric distension. Vagus stimulation explains why up to 40% of patients with inferior MI have sinus bradycardia (Bezold-Jarisch reflex). 1st to 3rd degree AV block is also common but how the mechanism of the AV node inhibition is not known.AST was for many years ago the only known cardiac marker. In the 1954 protocols for MI an elevated AST defined an acute coronary syndrome. Which in those days required hospitalization for bed rest mainly! It is a sensitive marker but highly nonspecific. LITFL (as usual) has an excellent article about the use LFTs, especially for the 'cut the crap' based approach of the emergeny physician
http://lifeinthefastlane.com/education/investigations-tests/liver-function-tests

All pain and physical stress, especially from stomach and intestines can potentially stimulate the vagus nerve and thereby cause bradycardia. The classical scenario is the elderly patient with gastroenteritis that comes to the ED after a syncope. The relationship between bradycardia and acute cholecystitis has actually been described previously and even given a special name, Cope's sign:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1795584/

Bradycardia in the case described above turned out to be caused by an underlying acute cholecystitis, the patient had an infusion and was admitted for emergency surgery. A new Troponin T was taken and turned out to be normal. A new ECG revealed normal sinus rythm.