Student cases

how far back to look

We bring back our Med Student Case of the Week, thanks David Brennan!

The patient is a 70’s y.o. man who is 2 weeks status post an inguinal hernia repair with placement of a peritoneal dialysis catheter as well.  He has been on hemodialysis and is hoping to transition to the peritoneal approach, he last dialyzed the day prior to arrival and has not missed any dialysis treatments.  He’s been having abdominal discomfort of one form or another since the surgery and has been constipated in addition.  The pain has intensified in the last day or so and is radiating down his legs as well.  He has been decreasing his post-op narcotics as directed and using his bowel regimen.  Prior surgical history also includes appendectomy and AAA repair.

Well. So at least we know it’s probably not his appendix.  Aside from that however, the differential is wide open.  I always counsel residents that if a patient has undergone a procedure of any type we always have to consider how that may be playing a role in the current symptoms.  Here obviously we would be concerned for some intra-abdominal complication of the surgery with the added feature of the newly placed PD catheter.  Side effects to medication need to be considered in most presentations.  An ob-gyn resident on my very first student rotation taught me something I try never to forget, The Hand That Writes The Narcotics Is The Hand That Writes the Bowel Regimen.  It’s very common to see constipation as a side effect of narcotic use, I generally recommend to any patient I’m putting on narcs that Colace should be used as a stool softener, Senakot stimulates the same receptor in the intestines that the narcotics block to offset the constipation, and that Miralax can be used if the above isn’t enough.  Furthermore I can tell you from personal experience of a laparascopic appendectomy that even without using narcotics post-op, it can take 2 weeks for the ileus to wear off after an abdominal surgery.

Did anything else stand out to you in the history?  We’ve just mentioned a bunch of abdominal possibilities, but this patient is reporting pain going down his legs.  That’s unusual for abdominal pain and much more consistent with back differentials.

On exam the patient is tachy to 110’s, but with a preserved blood pressure.  He is uncomfortable appearing.  Abdomen was reported as soft.  There is some bruising and somewhat of a cord sensation beneath the inguinal hernia repair.

Labs come back with a WBC count of 18, a Hgb of 8, bicarb of 19, and a lactate of 11.  The WBC count and the lactate stand out; they could certainly go along with an abscess.  But why is the Hgb low?  Shall we look at the CT scan?

aaa

Unfortunately not constipation.  Not an abscess either.  We can see contrast extravasating around the outside of the aortic hardware as well as a big retroperitoneal hematoma.  The second tertiary care center contacted was willing to explore options (the first felt there were none for a leaking re-do AAA), however, the patient and family ultimately elected for comfort care and against the transfer.

Takehomes?  First, looking at the CT, the AAA was probably palpable on exam; bedside USN may also have been useful.  Second, this case reiterates that differentials have to be wide, a person’s natural inclination would be to expect this case to have been a complication of the recent surgery rather than progression of a different problem.  Again, pain radiating down the legs is atypical for abdominal causes of pain.

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