Case for everyone: Elderly abdominal pain

[LT_Oneal_PAC]

While it’s a student case, I think anyone can participate as this is a good one. That doesn’t necessarily mean life threatening or zebra, but should be considered.

You are a rural solo provider at a CAH ED and also act as the Hospitalist for the inpatient service. You have access to most labs except no body fluid analysis outside urine and blood. Full CT capabilities. No US outside your own POCUS skills which is broad. No MRI. There is a back up IM physician on call who can relieve you, but who is being fired soon for chronic gross negligence unbeknownst to him. You have tele-nursing available that can assist with documentation by video as you only have 2 paramedics for ED staff. You can call for more assistance from inpatient floor that has 2 nurses. There are 8 non critical patients on the floor.

You shower and almost about to sleep at hour 21 of no sleep due to constant revolving doors of patients. At 0400 patient arrives and your called back to the ED with report of an 83 yof with abdominal pain.

arrives by PV with son. Pain occurred at 0100 and awoke her from sleep. Pain is reported 9/10. Says it just hurts when you ask for description. Localized to umbilical and lower abdomen. Does not radiate. Associated bloating and thinks she would feel better if she could pass gas or have BM. No exacerbating or relieving factors. Last BM yesterday where she reports pushing harder but successful normal BM. No nausea, vomiting, melena, BRBPR, or any other symptom you could think of in the entire ROS. Son visits twice daily and said she was fine last evening. Eating and drinking well. No problems with dinner. No complaints.
 

PMH: relatively healthy for age. Takes metoprolol. Chart reveals afib with RVR one year ago. She spontaneously converted to sinus rhythm and has been in NSR at every visit since. Cardiologist recommended thinners, but could not afford DOAC and refuses Coumadin. She has history of intermittent nausea. Prior appy and lapchole. Brain tumor decades ago that left her with left 7th nerve palsy.

VS: 65 P, 146/74 BP, 16 RR, 37C temp, 99% RA. Appears to be in NSR on tele.

She moans in pain every 10 seconds and appears in acute pain. Abdomen is tender just at areas of localized pain. You feel possible mass or localized distention in lower abdomen, other wise soft, non tender, no peritoneal signs.

what is your differential? What are your next actions?

 

 

 

[MediMike]

Hx of smoking? Recent palpitations?

Femoral pulses?

Any imaging records (old CTs?)

CBC/CMP/Lactate/Coags

12 lead

Start the CT spinning up while you throw the probe on her belly, what do you see? (Don't say a fetus because I didn't order an HCG)

[EMEDPA]

great case and very broad differential to include, but not limited to AAA, ischemic colitis, SBO, volvulus, intususception, pancreatitis, ovarian, uterine, or bladder pathology, metastatic dz or primary malignancy, hernia. Doubt acs given that story.

goals: hydrate, control pain, image with CT angiogram of abd/pelvis after fast u/s exam looking for free fluid, cbc, cmp, lipase, ekg, trop, INR, lactic acid, blood cultures, UA, UDS 

[MediMike]

6 minutes ago, EMEDPA said:

great case and very broad differential to include, but not limited to AAA, ischemic colitis, SBO, volvulus, intususception, pancreatitis, ovarian, uterine, or bladder pathology, metastatic dz or primary malignancy, hernia. Doubt acs given that story.

goals: hydrate, control pain, image with CT angiogram of abd/pelvis after fast u/s exam looking for free fluid, cbc, cmp, lipase, ekg, trop, INR, lactic acid, blood cultures, UA, UDS 

I think you might've missed an organ in there...wait...no...no guess not

[LT_Oneal_PAC]

17 minutes ago, MediMike said:

Hx of smoking? Recent palpitations?

Femoral pulses?

Any imaging records (old CTs?)

CBC/CMP/Lactate/Coags

12 lead

Start the CT spinning up while you throw the probe on her belly, what do you see? (Don't say a fetus because I didn't order an HCG)

 

9 minutes ago, EMEDPA said:

great case and very broad differential to include, but not limited to AAA, ischemic colitis, SBO, volvulus, intususception, pancreatitis, ovarian, uterine, or bladder pathology, metastatic dz or primary malignancy, hernia. Doubt acs given that story.

goals: hydrate, control pain, image with CT angiogram of abd/pelvis after fast u/s exam looking for free fluid, cbc, cmp, lipase, ekg, trop, INR, lactic acid, blood cultures, UA, UDS 

No smoking, EtOH, or drug history.

no palpitations. You ask about the a-fib and she’s very adamant it’s never bothered her since. Saw cards 2 weeks ago

femoral pulses +2 and equal. 
 

old CT from 2011 unremarkable for your purposes.

12 lead NSR. No stemi or equivalent. Normal intervals. No repol changes

CT is spun. Rad tech says she is waiting for Cr but you can override this. Do you want to?

what POCUS would you like to perform mike?
Fast negative

labs drawn. Urine looks clear (thank you for not asking for rapid Covid  but you do have that if you want

 

[LT_Oneal_PAC]

@MediMike @EMEDPA patient becomes diaphoretic, tearing, and BP spikes to 180. She is begging you for you to stop the pain.

[MediMike]

1 minute ago, LT_Oneal_PAC said:

 

No smoking, EtOH, or drug history.

no palpitations. You ask about the a-fib and she’s very adamant it’s never bothered her since.

femoral pulses +2 and equal. 
 

old CT from 2011 unremarkable for your purposes.

12 lead NSR. No stemi or equivalent. Normal intervals. No repol changes

CT is spun. Rad tech says she is waiting for Cr but you can override this. Do you want to?

what POCUS would you like to perform mike?
Fast negative

labs drawn. Urine looks clear (thank you for not asking for rapid Covid  but you do have that if you want

 

Most of my jam is above the diaphragm but i could probably find the aorta if (someone's) life depended on it.

83yo lady, concern for possible renal involvement if this IS a AAA/dissection... I'd hold the contrast and go for a regular old CT A/P

[MediMike]

Well dangit. Big gal or twig? 50mcg of fentanyl to start with. 

Any change to my exam? Pulses still good? How's the belly NOW? Are we rigid yet?

Edit: And was that "tearing" like boo hoo or "tearing" like a large blood vessel ripping sparo?

Edited June 29, 2020 by MediMike

[LT_Oneal_PAC]

11 minutes ago, MediMike said:

Most of my jam is above the diaphragm but i could probably find the aorta if (someone's) life depended on it.

83yo lady, concern for possible renal involvement if this IS a AAA/dissection... I'd hold the contrast and go for a regular old CT A/P

 

8 minutes ago, MediMike said:

Well dangit. Big gal or twig? 50mcg of fentanyl to start with. 

Any change to my exam? Pulses still good? How's the belly NOW? Are we rigid yet?

You are adept at aorta visualization in this scenario. You see the proximal to the branch point of renal arteries and no aneurysm or intimal flap noted, though you can’t be sure of the latter on this old US machine. The rest of the aorta cannot be visualized due to bowel gas.

she is actually about normal. 76kg. You give her 50 mcg and states her pain is unchanged, but you can tell she is a little more groggy, just a little.

exam is entirely unchanged.

you wait for a creatinine. I’ll wait to give results until emed says if he wants to wait or not.

any actions while you wait. It will be about 20 minutes.

[MediMike]

Well I'm heading out for a run, but...

Finish a physical exam: All peripherals pulses, skin signs, focused cardiac US exam, repeat the belly exam

Labs: Nothing else really, can we switch anything from lab run to POC? 

Another 25mcg, with orders to admin another 25 if she's maintaining her airway ok. Repeat vitals after analgesia, is that BP still climbing? 

...how fast can you shoot a KUB? (She's 83, gotten all the rads already in her life, plus she's probably on Medicare so I'll spot the bill on this one)

[LT_Oneal_PAC]

@MediMike
Exam unchanged. Cardiac US shows no hypokinesis, RV strain, mconnell sign, and EPSS <7mm.

BP stable are 180

no point of care but since we don’t know when emed will be back I’ll tell you.

labs that both ordered are normal except lactic 2.4

you give 25mcg and she drops sats to 65% and appears asleep. Stet also fun arouses her, NC applied, follows commands to deep breaths, returns to 97%

a KUB would take about 10 mins. But you asked for a CT and it shows some small bowel edema and maybe some fat stranding at small bowel. Note endometrial thickening, possibly malignant. Difficult to say without contrast. No history of vaginal bleeding. Otherwise unremarkable. It will be 30 mins for rads to read

[LT_Oneal_PAC]

@EMEDPA

 

ill assume you want to roll forward with CTA, as this will be next step for medimike and now his Cr is normal.

CTA shows more definition. Definitely no dissection or aneurysm. The celiac has mild stenosis, but patent. SMA patent. You see there is mesenteric edema and small bowel edema. You think maybe could be venous congestion, but the venous also is well enhanced. You aren’t adept enough at the CTA to tell about distal mesenteric perfusion, maybe some loss at the very end to one artery branch next to mesentery? More sure of the endometrial thickening.

You call the telerad company to place at the top of there list, but it will still be 30 mins before read because they suck.

[LT_Oneal_PAC]

What do we think about the normal labs other than lactic? I will add there is a normal dimer.

After about 10 minutes from last fentanyl, she is begging again for you to stop the pain.

[LT_Oneal_PAC]

49 minutes ago, MediMike said:

Well dangit. Big gal or twig? 50mcg of fentanyl to start with. 

Any change to my exam? Pulses still good? How's the belly NOW? Are we rigid yet?

Edit: And was that "tearing" like boo hoo or "tearing" like a large blood vessel ripping sparo?

It was crying. Still won’t define pain

[LT_Oneal_PAC]

Oh forgot to mention. She was burping a lot earlier. After CTA she is vomiting bile.

[MediMike]

Back! Sorry. Dog was super slow. Definitely wasn't me being slow. For sure not me.

Well yay! Absolute immediate life threats of aneurysm/dissection are rules out in my mind. Thanks for the dimer btw, by the time I thought of it we were only a couple minutes away from out CT.

She sounds like she's shaping up more along the lines of an SBO, unclear etiology, can consider adhesions from her two prior surgeries or there's the potential of an intraluminal metastatic bit from her possible uterine cancer.

I don't suppose she vomited any of the oral contrast we gave her...?

Issues at the moment are control of nausea and pain, await formal read followed by admission and likely surgical consult for SBO... depending on the final read of course. I would not decompress as there was no comment on gastric distension, distended loops etc.

Labs in the elderly can be rough, will often not see them mount a robust response. This is fairly acute without significant vomiting (yet) so I'm not surprised there's normal renal function.

Edit: 4mg Zofran, let's try a cautious 5mg of morphine for something a little longer acting. Have one of the medical hold a jaw thrust if need be. And how about 500 of LR for good measure.

Edited June 29, 2020 by MediMike
Txmt

[LT_Oneal_PAC]

57 minutes ago, MediMike said:

Back! Sorry. Dog was super slow. Definitely wasn't me being slow. For sure not me.

Well yay! Absolute immediate life threats of aneurysm/dissection are rules out in my mind. Thanks for the dimer btw, by the time I thought of it we were only a couple minutes away from out CT.

She sounds like she's shaping up more along the lines of an SBO, unclear etiology, can consider adhesions from her two prior surgeries or there's the potential of an intraluminal metastatic bit from her possible uterine cancer.

I don't suppose she vomited any of the oral contrast we gave her...?

Issues at the moment are control of nausea and pain, await formal read followed by admission and likely surgical consult for SBO... depending on the final read of course. I would not decompress as there was no comment on gastric distension, distended loops etc.

Labs in the elderly can be rough, will often not see them mount a robust response. This is fairly acute without significant vomiting (yet) so I'm not surprised there's normal renal function.

Edit: 4mg Zofran, let's try a cautious 5mg of morphine for something a little longer acting. Have one of the medical hold a jaw thrust if need be. And how about 500 of LR for good measure.

Lol! I’m sure the dog was puffing trying to keep up.

4mg of Zofran ineffective. Another 4mg given still no relief. She continues to wretch and vomit bile. Morphine is ineffective. She is now writhing saying she wants to die if it will stop the pain. Maybe it’s the lack of sleep, but it’s actually emotionally disturbing to watch.

the read comes back stating mostly what you’ve already noted, and you roll your eyes about why your hospital pays these people, and says celiac 50% stenosed but patent. SMA patent. No venous thrombosis. Mesenteric edema possible from venous congestion. No pneumotosis, free air or fluid. Mild bowel edema with no dilation. Cannot rule out ischemic enteritis. Confirm possible uterine malignancy. No sign of mets. 
 

You have an agreement with the academic center 1.5 hours away by ambulance, 30 minutes by helicopter, and they will consult on any patient you wish. The answer is almost always the same, send her and they’ll figure it out for you. Would you like to call them? they will also say snarky things like what is your clinical question for the consult. You have no surgeon except on thursday during the day at this facility (it’s not Thursday). you also have the option to transfer ED to ED without consulting the surgery service at the academic center. Just have to call the transfer line to speak with the ED for accepting physician. Transfer by ambulance usually requires about 30 minutes for second crew to arrive for transport. If you are very concerned for emergent life threat, you can call the helicopter and they will auto launch on your authority even without accepting physician established, it will be auto accepted to the academic center.

1L NS given and lactic now 1.7

Anything else we can try for pain? Would you like anything else for nausea? She’s still hemodynamically stable. What are we thinking now after CTA read? This is a real doozy case. 

 

[MediMike]

45 minutes ago, LT_Oneal_PAC said:

Anything else we can try for pain? Would you like anything else for nausea? She’s still hemodynamically stable. What are we thinking now after CTA read? This is a real doozy case.

Of course it's not Thursday.  It's never Thursday.

Item One: Symptoms

- No relief from anti-emetic, no relief from analgesia, let's combine the two into one form and try some haloperidol, 5mg.  If it doesn't work for the pain maybe it'll make her a little wonky and relieve some of my caregiver guilt for being unable to manage her pain appropriately.  Next step would be ketamine

Item Two: Dispo

I have a significant concern for an SBO w/ some relation to the possible malignancy vs an adhesion issue, although they didn't call a transition point the mesenteric/small bowel edema is consistent with that picture.  With that being said, if she has an active malignancy you've got to be thinking of a potential hypercoag state which could predispose to venous thrombosis (although I just saw they excluded that on the read).  Lactate is honestly not all that impressive for a enteric ischemia. 

I'd call the surgical service "Hey it's MediMike from Rural CAH.  Now, I'm just a simple country PA but I've got a lady with intractable belly pain and a CTA demonstrating small bowel and mesenteric edema, happily there's no significant occlusive dz noted but unfortunately there's a likely active uterine malignancy.  MY CLINICAL QUESTION FOR CONSULT is would this poor woman be best served receiving care at your facility as she will likely require an advanced workup? She is hemodynamically stable and has been resuscitated to a normal lactate."

[GetMeOuttaThisMess]

Anyone want to help this lady with her nausea/perception of need for a BM/pass gas aside from using pharmaceutical agents?  I know what I'd be doing which is go old school.  I want to see her bowel gas pattern which you aren't going to be able to see with her supine.  Tilt the table and get a quasi upright KUB (air fluid levels?) and stick an NG tube down her (she has edematous bowel).  Are sx. exacerbated based on positioning?  My initial concern for her aside from the AAA would have been mesenteric ischemia (hx. of AF and not on anti-coagulants) or even renal lithiasis (been there, done that).  You don't have to worry about the female trifecta (appy, GB, or bambino).

Edited June 29, 2020 by GetMeOuttaThisMess

[MediMike]

1 hour ago, GetMeOuttaThisMess said:

Anyone want to help this lady with her nausea/perception of need for a BM/pass gas aside from using pharmaceutical agents?  I know what I'd be doing which is go old school.  I want to see her bowel gas pattern which you aren't going to be able to see with her supine.  Tilt the table and get a quasi upright KUB (air fluid levels?) and stick an NG tube down her (she has edematous bowel).  Are sx. exacerbated based on positioning?  My initial concern for her aside from the AAA would have been mesenteric ischemia (hx. of AF and not on anti-coagulants) or even renal lithiasis (been there, done that).  You don't have to worry about the female trifecta (appy, GB, or bambino).

Having an NG tube placed has consistently been ranked as one of the most painful procedures that occur in the hospital, unless I saw evidence of distension/dilation I'd probably hold off. 

If there wasn't a CT revealing no gaseous distention/dilated loops I'd be in total agreement.

But I'm an upstairs guy, if you all want to stick the tube in before you send her up I'll gladly commiserate over how mean those ED people are

[GetMeOuttaThisMess]

She's asking for relief that medication hasn't provided.  She also says she thinks that belching/defecating would help.  She's vomiting bile as well.  I'll put it in for you.  NG isn't for anything other than decompression of the GI tract.  If it can't come out one end, relieve the pressure from the other.  It in this instance can also be used as a diagnostic/therapeutic tool.

Edited June 29, 2020 by GetMeOuttaThisMess

[LT_Oneal_PAC]

10 hours ago, MediMike said:

Of course it's not Thursday.  It's never Thursday.

Item One: Symptoms

- No relief from anti-emetic, no relief from analgesia, let's combine the two into one form and try some haloperidol, 5mg.  If it doesn't work for the pain maybe it'll make her a little wonky and relieve some of my caregiver guilt for being unable to manage her pain appropriately.  Next step would be ketamine

Item Two: Dispo

I have a significant concern for an SBO w/ some relation to the possible malignancy vs an adhesion issue, although they didn't call a transition point the mesenteric/small bowel edema is consistent with that picture.  With that being said, if she has an active malignancy you've got to be thinking of a potential hypercoag state which could predispose to venous thrombosis (although I just saw they excluded that on the read).  Lactate is honestly not all that impressive for a enteric ischemia. 

I'd call the surgical service "Hey it's MediMike from Rural CAH.  Now, I'm just a simple country PA but I've got a lady with intractable belly pain and a CTA demonstrating small bowel and mesenteric edema, happily there's no significant occlusive dz noted but unfortunately there's a likely active uterine malignancy.  MY CLINICAL QUESTION FOR CONSULT is would this poor woman be best served receiving care at your facility as she will likely require an advanced workup? She is hemodynamically stable and has been resuscitated to a normal lactate."

For you, its quite literally never Thursday because your shift always starts Thursday night at 9. Sucks to be you.

- you give her 5mg haloperidol and she’s out. Breathing. Intermittently you hear her moan in pain. 
 

-you call the academic center and punch 3 on the automated system for consult. The annoying music starts and tells you that you’re call will be answered in the order it was received. It’s 0530 and it’s getting about time for shift change, you remember from your time as a resident there. It’s been 20 mins and no answer (this really happened, not being a dick for the case). The lazy paramedic, that looks 20 years older than stated age, who really doesn’t want to drive 1.5 hours ever, but very experienced and good, asks if you want the chopper to launch.

2 hours ago, GetMeOuttaThisMess said:

Anyone want to help this lady with her nausea/perception of need for a BM/pass gas aside from using pharmaceutical agents?  I know what I'd be doing which is go old school.  I want to see her bowel gas pattern which you aren't going to be able to see with her supine.  Tilt the table and get a quasi upright KUB (air fluid levels?) and stick an NG tube down her (she has edematous bowel).  Are sx. exacerbated based on positioning?  My initial concern for her aside from the AAA would have been mesenteric ischemia (hx. of AF and not on anti-coagulants) or even renal lithiasis (been there, done that).  You don't have to worry about the female trifecta (appy, GB, or bambino).

There are no air fluids levels, pain is worse with positioning.

I’ll reveal part of the real story: we skipped the Cr and went straight for the CTA as I was number one concerned for ischemia and lesser AAA or dissection as their was no radiation to the back, gave 50mcg of fentanyl, and she couldn’t lay flat for the CT. Gave her another 50mcg and she stopped breathing. I held oxygen to her face and gave her breathing commands that she followed while they zipped her through the scanner. I was wearing lead for the radiation.

despite just stopping breathing, she was writhing again by the time we walked back to the ED and vomiting bile. I gave her 10mg ketamine and she was resting peacefully for about 5 minutes during which time I had them slam in a NG as I thought this might be my only opportunity and I was getting concerned with everything I gave her affecting airway and know she is going to get transported. Green bile initially then brown. Patient awake again and sat up, XR with tube in place.

I’ll reveal the rest later after medimike finishes  you’re doing good, it’s just a shitty day at the CAH

 

[GetMeOuttaThisMess]

Need to think about a zebra such as intestinal angioedema though not reportedly on ACEI/ARB.  Still don't know about endometrial CA.

[LT_Oneal_PAC]

@GetMeOuttaThisMess Mike’s close to the end and there are learning points in the transfer, at least from a rural CAH stand point. Academic centers more urban sites don’t have to deal with transport time, weather, getting someone on the phone. It was a case with tons of pitfalls that I’m not sure if I was good or too lucky and stubborn/tired that I didn’t fall into.

the diagnosis is quasi-zebraish. It can be assumed clinically, but the true cause will only be made in surgery upon direct visualization.

 

[LT_Oneal_PAC]

If anyone has other thoughts ideas at what they would have done, please share. Disagreement isn’t personal. This is the art of medicine and we should openly discuss to all be better