Student cases

the Turkey bites back

just not this kind of Turkey.

Happy Thanksgiving to all, and thanks to Elle Schultz who brings us our Student Case of the Week.

Our patient is a 50’s y.o. man presenting to the ED with severe epigastric abdominal discomfort that started abruptly about 45 minutes prior to arrival while drinking coffee.  He did have nausea and vomiting.  Discomfort is described as 10/10 and radiates to his back.  He is quite uncomfortable looking.

So.  When I’m orienting students we discuss what the goals of a history are for different levels of trainees.  A 3rd year student is essentially in the reporter stage, responsible for collecting the history and regurgitating it back in a semi-coherent fashion.  A 4th year student needs to move on to analyzing the differential and asking the pertinent positives and negatives that will move items up and down the differential, in this case for severe epigastric pain.  The first 2 things that spring to mind are pancreatitis and peptic ulcer disease.  Cholecystitis is still very much there.  Transverse colitis can cause pain in this area, we should ask about diarrhea.  Cardiac causes must be considered with epigastric pain as well.  That’s not saying you have to send troponins on every patient you see with epigastric pain, but your chart has to reflect that you thought about it and asked the patient about cardiac risk factors or worsening of discomfort with exercise etc.

In this case, let’s look first at pertinents for pancreatitis.  Does he drink?  Well, as it turns out he drinks about a pint of hard liquor (Wild Turkey whiskey, if you can believe that) plus additional beer on a daily basis.  What about Peptic Ulcer Disease?  The alcohol is a positive mark in its column as well.  What’s more he takes NSAID’s on a daily basis, though his Meloxicam should be less worrisome than if it was naproxen or ketorolac.  He denies any history of this pain occurring after eating fatty foods.  Furthermore, when asked specifically about ulcers he reports he did have a gastric ulcer previously.  He denied any exertional component to this or other discomforts.

On exam he has generalized discomfort to light palpation, as well as rebound tenderness and guarding.

So he has peritonitis.  If he doesn’t have pancreatitis then he’s going to get imaged.  We’ll cut to the chase.  The lipase was normal.  The first step in imaging is going to be provider dependent.  A lot of students propose abdominal plain films in their work-ups that are presented to me.  You need to ask yourself what you’re looking for.  If the answer is free air or a bowel obstruction that’s fine, go ahead and proceed, with the caveat that if you’re fairly certain your surgeon is going to want a CT scan even if positive then you may be better off skipping to the CT.  If you are highly concerned for a perf then water-soluble contrast is slightly less irritating to the peritoneum than barium is, but it’s not harmless either.  In this case the team elected for the upright chest centered on the diaphragm.

free air 1117

Can you see the free air under the right diaphragm?  A call was made to surgery, he was started on antibiotics, and he was in the OR within an hour of presentation where a 3mm perf to the gastric fundus was repaired.  As a general rule small amounts of air are more likely to come from perfed ulcer disease whereas large amounts of free air are more likely from colonic perfs.

Take-homes?  I think the biggest one is that while we try not to order a ton of abdominal plain films since they’re only helpful in a narrow range of pathologies, if you do suspect either free air or bowel obstruction and have a surgeon willing to act/observe based on a clinical exam and an x-ray then plain radiographs will save your patient radiation and time in your department.  Another is that while meloxicam is a COX-2 inhibitor and so less likely to cause ulcers, its risk is not zero.  It’s impossible to know how much is attributable to the medicine and how much to the alcohol, but certainly they’re not a great mix in any case.

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