Clinical scenario: dark stool, abdominal pain, elevated liver enzymes

[MacGyver]

No other symptoms. Pt describes pain as being in stomach area. Pt is 69 y/o male taking lipitor and atenolol. Pt has history of ulcers, hemorrhoids.

Vomiting (dry heaves) began approx 4 days ago but lasted only for a couple of days and then went away. About the same time, Pt had a couple of episodes in which he passed noticeably dark stool (upper GI bleed?). Pt describes "stomach" pain that waxes and wanes, and began to improve gradually on day 2 and 3. Morning of day 4, patient palpates his own abdomen and immediately falls to his knees in pain, describing it as a 10/10 on the pain scale, "the worst pain I've ever had."

Pt is admitted to hospital. Pain gradually improves and patient no longer needs any pain meds. Abdominal ultrasound unremarkable. Liver enzymes (AST/ALT) elevated. All other bloodwork, including pancreatic enzymes are normal.

Pt is married in a monogamous relationship with no outside sexual history (partner has no symptoms and is likewise monogamous). Pt denies being exposed to blood or other bodily fluids. Pt has no history of alcohol use.

Yes, I realize this is limited info. Give me your diff dx and give +/- for each possible diagnosis.

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[Masonator]

No other symptoms. Pt describes pain as being in stomach area. Pt is 69 y/o male taking lipitor and atenolol. Pt has history of ulcers, hemorrhoids.

Vomiting (dry heaves) began approx 4 days ago but lasted only for a couple of days and then went away. About the same time, Pt had a couple of episodes in which he passed noticeably dark stool (upper GI bleed?). Pt describes "stomach" pain that waxes and wanes, and began to improve gradually on day 2 and 3. Morning of day 4, patient palpates his own abdomen and immediately falls to his knees in pain, describing it as a 10/10 on the pain scale, "the worst pain I've ever had."

Pt is admitted to hospital. Pain gradually improves and patient no longer needs any pain meds. Abdominal ultrasound unremarkable. Liver enzymes (AST/ALT) elevated. All other bloodwork, including pancreatic enzymes are normal.

Pt is married in a monogamous relationship with no outside sexual history (partner has no symptoms and is likewise monogamous). Pt denies being exposed to blood or other bodily fluids. Pt has no history of alcohol use.

Yes, I realize this is limited info. Give me your diff dx and give +/- for each possible diagnosis.

Appendicitis -, ulcers + w/perforation, stomach cancer w/mets, Any GI cancer with mets and/or psbo/plbo. Gallstone ileus++, GI bleed w/superimposed hepatitis or fatty liver-. Liver failure with portal HTN, varyx bleed-, psbo w/ superimposed GI bleed from ulcer-. Hepatocellular carcinoma with invasion into surrouding tissues and celiac plexus, cholecytitis, choledocholithiasis, clonorchis infection.

It would help if we could guaiac the dark stool. A CT scan would be immensely helpful as well.

 

[dr.smurf]

this pt needs an egd to investigate the upper gi tract. because of his acute onset of severe abdo pain with a hx of ulcers u must r/o a perf. get a stat cxr upright and look for free air under the diaphragm.

the elevated lfts could be a coincidental finding secondary to statin therapy or could mean liver involvement of a gastric ca. ??? any wt loss?

given this guys age he needs to worked up for malignancy for sure. let us know what u find!

 

[doc05]

the typical medicine attending would say that your history sucks and is grossly incomplete. I would agree.

AST/ALT elevated? how high? was a GGT obtained? ALP? why is the pt. on atenolol?
what about follow up for peptic ulcer disease? were the ulcers treated? with what? when?

how much vomiting? how much volume was lost? was the vomitus grossly bloody? did the pt collect a sample for laboratory analysis?


I am curious as to why you included the sexual history (which is not clearly indicated in this case), while there are so many gaps within your presentation.

did you even think to do a physical exam? what did you find?

I disagree re: the usefulness of a stool guaiac. It's not useful because the result won't change your management. Nor is the test particularly accurate.

Management: admit to medicine. surgical consult. D51/2NS at 120 cc/h. Place NG tube. CXR; KUB. RUQ sono. CT abd/pelvis. GI consult for EGD.

 

[Masonator]

the typical medicine attending would say that your history sucks and is grossly incomplete. I would agree.

AST/ALT elevated? how high? was a GGT obtained? ALP? why is the pt. on atenolol?
what about follow up for peptic ulcer disease? were the ulcers treated? with what? when?

how much vomiting? how much volume was lost? was the vomitus grossly bloody? did the pt collect a sample for laboratory analysis?


I am curious as to why you included the sexual history (which is not clearly indicated in this case), while there are so many gaps within your presentation.

did you even think to do a physical exam? what did you find?

I disagree re: the usefulness of a stool guaiac. It's not useful because the result won't change your management. Nor is the test particularly accurate.

Management: admit to medicine. surgical consult. D51/2NS at 120 cc/h. Place NG tube. CXR; KUB. RUQ sono. CT abd/pelvis. GI consult for EGD.

You are pretty tough,chewing MacGyver out like he is doing a subI right now. I guess he won't get that honors for studentdoctor.net patient workups, or maybe he was trying to summarize a patient without having to type out a full medical student H&P. A guaiac might be useful to rule in blood. If it does come back positive it will help to narrow the differential down a bit. If the EGD came back negative, would you discount the dark brown stool. Would you do colonoscopy before getting a guaiac? These are concerns that GI might want to know. How would a vomit sample change our plan since we are talking about unecessary tests?

Last I checked he wanted to work through a differential, and get some support for one thing vs. another. Now he knows what orders to write but not necessarily why.

 

[dr.smurf]

first things first...you do need to guiac the stool! one...it will make you do a rectal which none of us like to do, but is necessary. two...it will help guide your investigations and differential. never let anyone tell you not to guiac or do a rectal. if its positive then you know their is an UGI bleed and an egd is needed. if its negative then the egd may not be needed as urgently as you thought. oh and as an aside pepto bis is notorious for causing black stools and if hes had n/v he may have taken it to remedy that.

oh and if you go with doc O'5s management you will look like you dont have a clue with whats going on and cant work up a stumped toe. i mean come on...a nurse can ramble off "admit to medicine, get a surg consult, start D51/2NS, and contact GI". thats hilarious!! what are u going to tell these people besides you didnt come up with s*** as a differential and didnt order s*** for a workup. please please dont get in that habit. it makes you look very bad.

a good h&p will give you 90% of the diagnoses. so this should be priority and then comes your basic workup like blood tests and imaging. do work on summarizing pertinent pt info beginning always with age and sex and CC!

 

[doc05]

You are pretty tough,chewing MacGyver out like he is doing a subI right now. I guess he won't get that honors for studentdoctor.net patient workups, or maybe he was trying to summarize a patient without having to type out a full medical student H&P. A guaiac might be useful to rule in blood. If it does come back positive it will help to narrow the differential down a bit. If the EGD came back negative, would you discount the dark brown stool. Would you do colonoscopy before getting a guaiac? These are concerns that GI might want to know. How would a vomit sample change our plan since we are talking about unecessary tests?

Last I checked he wanted to work through a differential, and get some support for one thing vs. another. Now he knows what orders to write but not necessarily why.

the vomit sample? I was being facetious.

I still disagree about the guaiac. You will of course do it out of habit, but it will NOT change your management. Oftentimes we are asked to do rectals for no other reason than the amusement of the resident or attending.

Based on history alone, you would suspect upper GI bleed. EGD is therefore indicated. Would you decide against EGD if guaiac came back negative? Of course not. Similarly, a positive guaiac tells you nothing. After all, hemorrhoids and red meat in the diet can give a (+) result.

and I was not "chewing out" anyone. I suspect MacGyver is an MS-II and therefore not used to providing concise, directed patient presentations. He will learn.

 

[Sveet07]

69 y.o man w/ 10/10 abdominal pain? symptoms more extreme than physical findings? did the hosp. check his LDH level to r/o MI (mesenteric ischemia)?

what about acute abdominal series? dark stools? something to r/o also is intussusception. i saw one case like this on GI service.

if this had been a female perihepatitis (Fitz-Hugh-Curtis) is in ddx

 

[Idiopathic]

Just a second year here...doesnt statin therapy potentially cause fulminant hepatitis and myoglobinuria? Could these be conincidental findings here? What in the Hx suggests otherwise?

Other than that, it sounds like ischemic colitis/mesenteric angina to me. I can afford to make rash judgements like that tho

 

[Whisker Barrel Cortex]

With the limited information provided these are my thoughts:

Summary: Vomiting, maybe melena (does not sound like a large volume acute bleed). Epigastric pain improved relatively quickly with no intervention noted. Elevated ALT and AST, but no evidence of pancreatitis, biliary obstruction (I assume labs included bilirubin, GGT, Alk Phos), no anemia (assuming CBC was one of the labs that were normal).

Given this history there are a several of possibilities:

Acute hepatitis, possibly related to lipitor. By the way, lipitor can also cause melena, severe abdominal pain in addition to the elevated LFTs. These are relatively rare. Other causes of hepatitis should be evaluated (hepatitis panel). By the way, ultrasound cannot evaluate with good sensitivity for acute hepatitis.

Duodenal or gastric ulcer with slow bleed is still a possibility. In this case, the elevated LFTs may be a red herring related to Lipitor. This would fit with the vomiting, abdominal pain, and melena. However, given improvement in the pain, bowel perforation is extremely unlikely. EGD should be performed.

Varices with bleed are unlikely given lack of signs of cirrhosis on ultrasound. However, bleed from mallory weiss tear is another possiblity given the extent of vomiting.

Partial SBO could have these symptoms, including the vomiting and melena. LFT elevation would be a separate issue. Has the patient had prior surgeries?

Normal RUQ ultrasound and normal pancreatic enzymes = no chance of gallstone ileus. Improved symptoms and lack of lower abdominal symptoms, fever, leukocytosis makes appendicitis very unlikely. Acute mesenteric ischemia is a good thought, but rapid improvement in the pain argues against this possiblity.

Abdominal x-ray should have been early on to eval for PSBO or free air. Now that the pain is improved, evaluation changes. First do the EGD to eval for ulcer, varices etc. At this point, with the pain improved, Abd X-ray is low yield. Abdominal / Pelvic CT would be better for evaluating for mass or adhesion causing PSBO. It could also eval for varices, enlarged liver, or cirrhosis. If a triphasic CT is performed, you could even get info on the mesenteric vessels. A lot of information to be had from a single test.

In the meantime patient should be off of lipitor and on a PPI. If continued melena, H/H should be followed until the cause is clear.

 

[Masonator]

the vomit sample? I was being facetious.

I still disagree about the guaiac. You will of course do it out of habit, but it will NOT change your management. Oftentimes we are asked to do rectals for no other reason than the amusement of the resident or attending.

Based on history alone, you would suspect upper GI bleed. EGD is therefore indicated. Would you decide against EGD if guaiac came back negative? Of course not. Similarly, a positive guaiac tells you nothing. After all, hemorrhoids and red meat in the diet can give a (+) result.

and I was not "chewing out" anyone. I suspect MacGyver is an MS-II and therefore not used to providing concise, directed patient presentations. He will learn.

I agree with you about the EGD, in fact if the patient was worrisome on PE and extremely sick I might go to the OR right away without and EGD. You may be right about the guaiac, however if you get to the colon cancer with mets stage of the differential diagnosis you may need colonoscopy, and GI might bich you out for not guaicing. Its one of those easy tests that can save you a headache later when a GI fellow refuses to do endoscopy until you guaiac thier next bowel movement. I guess you come from the school of hard knocks when you tell a student that their history sucks as part of the "learning process".

 

[Masonator]

Just a second year here...doesnt statin therapy potentially cause fulminant hepatitis and myoglobinuria? Could these be conincidental findings here? What in the Hx suggests otherwise?

Other than that, it sounds like ischemic colitis/mesenteric angina to me. I can afford to make rash judgements like that tho

That is good, I knew I forgot something on my differential!

 

[Masonator]

Normal RUQ ultrasound and normal pancreatic enzymes = no chance of gallstone ileus. Improved symptoms and lack of lower abdominal symptoms, fever, leukocytosis makes appendicitis very unlikely. Acute mesenteric ischemia is a good thought, but rapid improvement in the pain argues against this possiblity.

I'm not sure about this, could you explain why you would have elevate pancreatic enzymes and u/s findings w/ a gallstone ileus? You may not necessarily be febrile. I would like to know this for my own knowledge.

 

[Idiopathic]

I'm not sure about this, could you explain why you would have elevate pancreatic enzymes and u/s findings w/ a gallstone ileus? You may not necessarily be febrile. I would like to know this for my own knowledge.

You would see an obstruction on xray, I think, although they do not always have enough Ca++ to visualize, proximal signs of obstruction would be present. US is apparently taking over as it can Dx ileus earlier. Absence of pancreatic enzymes does not rule out gallstone ileus, however. MC location is the ileocecal junction, and I would think you would see signs of dilation proximal to the obstruction.

 

[Kalel]

I have a few thoughts about the case. Melena is typically caused by an upper GI bleed and is caused by the iron found in blood being oxidized by the acid in your stomach. I wouldn't rely on just a history of dark stools to say that the patient had melena though, since a lot of patients will say that they have "dark stools" but won't have melena (which is typically almost black). This would be a few of the diagnosis on my differential (and I say a few because the history is vague enough to have a pretty broad differential). Without knowing exactly what the liver enzymes were, we don't know if this is a normal "elevation" or a pathologic elevation.
1. Mesenteric ischemia: This would be highest on my differential given the history of severe abdominal pain that waxes and wanes. This type of pain is typically described as a post-prandial pain, and can cause emesis and dark or bloody stools. The patient's age and the fact that he's on lipitor all suggest arteriosclerosis being present, which is the most common cause of mesenteric ischemia. Patients typically describe this pain as the worst pain of their life, and their pain is usually out of proportion to what you see on abdominal exam. It would have been nice to know if the abdominal u/s included doppler flow studies of the mesenteric and other abdominal arteries, but a normal doppler study wouldn't have excluded the diagnosis.
2. Ulcer: Could just be the ulcer acting up; the patient isn't on any ulcer therapy. A chest x-ray is actually the best film to see free air under the diaphragm, even though I don't think that the history points very strongly to a gastric or duodenal perforation and chemical perotonitis because the patient recovered. The fact that he recovered from this pain helps exclude several conditions on our differential. I wouldn't exclude a perforation though, since small perforations can spontaneously close.
3. Iatrogenic: ie Lipitor. It'd be nice to know exactly what the enzymes were, but this could just be a case of abdominal wall pain with myositis and hepatitis (liver enzymes).
4. MI: Inferior wall MI could certainly cause epigastric pain that is now relieved. Would like to see ECG and probably get at least one set of cardiac enzymes.
5. Abdominal aortic dissection: Could be causing bowel ischemia.
Anyways, to start off, I'd go back and talk with the patient more. It would have been nice to know what was associated with the pain (eg post-prandial, early morning, etc); any changes in bowel habits or diet, any sick contacts, ulcer history, when he started Lipitor and what his liver enzymes have been like in the past, past w/u for dark stools, any fever/chills, what he means by painful abdomen, pain localized to epigastric region only, etc. Social history with alcohol and drug history would have been nice. New diagnostic tests I'd like to see include the results of an abdominal CT done with oral water-soluable contrast (in case of perforation) and IV contrast and ECG. Here's a neat website that helps people with abdominal pain differentials:
http://merck.praxis.md/index.asp?page=bpm_brief&article_id=BPM01GA12

 

[Kazu]

So, MacGyver give us the follow up. What tests were done, any working diagnosis?

 

[Masonator]

You would see an obstruction on xray, I think, although they do not always have enough Ca++ to visualize, proximal signs of obstruction would be present. US is apparently taking over as it can Dx ileus earlier. Absence of pancreatic enzymes does not rule out gallstone ileus, however. MC location is the ileocecal junction, and I would think you would see signs of dilation proximal to the obstruction.

He was talking about RUQ U/S wasn't he. We are not going to U/S the whole abd. That is the part I don't get.

 

[MacGyver]

OK, first let me say that I know the history info I gave sucks. The reason it sucks is because I"m getting this info 2nd hand from his wife. He lives far away and I have no access to him. I cant physically examine him. He is in the hospital and everything I've been told is coming from his docs there, thru his wife, and to me.

Without knowing exactly what the liver enzymes were, we don't know if this is a normal "elevation" or a pathologic elevation.

Liver enzymes were around 900 when first admitted, but have since declined (in one day) to about 700.

Pt was taken off lipitor as soon as he was admitted to hospital.

The docs have ruled out ulcers. They didnt do an endoscopy so I dont know how they ruled it out.

Docs have also ruled out gallstones. They ran an abdominal ultrasound, so I dont know if they used that to rule it out or what.

Social history with alcohol and drug history would have been nice.

I gave the sexual history info because I thought hepatitis might be a possibility, so IMHO given his sexual history and denying contact with blood or other body fluids, Hep A seems the only virus that he could have gotten. Pt does not take any illicit drugs, no contact with body fluids/blood, and is 100% monogamous with his wife regarding sexual contact.

I also thought about CMV. CMV is normally self-limited though and relatively benign. Pt is not immunocompromised, so I assumed that CMV shouldnt cause that much of a problem for him.

For some reason the docs dont think its Lipitor hepatotoxicity either. I dont know why they are downgrading this possibility. What % of patients taking lipitor get this?

I also found out that this Pt takes one aspirin every day. I thought this may cause NSAIDS hepatotoxicity and GI bleeding. Is one aspirin a day enough to cause liver problems or GI bleeding?

Pt takes atenolol for HTN. His BP in the hospital is normal.

The wife is frustrated because she gets the impression the docs are not doing anything. They are now testing for hepatitis. They are running bloodwork q8h (I dont know what specific blood tests they are running).

The only imaging studies that have been run is abdominal (RUQ?) U/S. No CT or x-rays were taken.

 

[MacGyver]

As far as mesenteric ischemia/ischemic colitis, wouldnt that arise in a slow fashion?

This Pt was fine on Saturday morning, but very sick by Sunday morning and bedridden.

 

[sanfilippo]

i came to this thread a bit late..."dark" stools, as Kalel pointed out, means nothing to most doctors. if you ask, "have your stools appeared as dark as my black stethoscope here (point to the tubing)?" and the pt says no, it's a good chance he does not have melena.

did he have heme(+) stools or not? is he anemic? if the answer is yes to both of these, he needs to be scoped. if ugi bleed is likely, he needs an NG to check the effluent and may then need PPI and octreotide in the mean time.

RF's for UGI bleed? EtOH? NSAIDs? prior h/o PUD?

also, does he have RFs for viral hepatitis? high-risk sex? IVDA? blood transfusions?

you keep saying his liver enzymes are high...are we talking AST and ALT? is there any elevation in the total bilirubin, conjugated bilirubin, alk phos?

also, n/v, abd pain, elevated LFT's: always add the broad category of vasculitis to the d/dx...you never know! you can always check an ESR but won't be too specific. okay, that's the rheum in me talking...
-s.

 

[MacGyver]

I'll call her again and try to get more info as far as specific bloodwork and specific liver enzyme levels.

 

[Kalel]

While you are speaking with her, tell her to communicate more with her doctor. Sometimes it helps to write questions that she may have down so that she can remember to ask her doctor when he or she is present. Too many patients don't ask their physician what's going on with their care, and then they get frustrated with their doctor for not answering all of the questions that they never asked. It's possible that the "blood work" being drawn q8h are cardiac enzymes to rule out an MI.

 

[Whisker Barrel Cortex]

Normal RUQ ultrasound and normal pancreatic enzymes = no chance of gallstone ileus. Improved symptoms and lack of lower abdominal symptoms, fever, leukocytosis makes appendicitis very unlikely. Acute mesenteric ischemia is a good thought, but rapid improvement in the pain argues against this possiblity.

I'm not sure about this, could you explain why you would have elevate pancreatic enzymes and u/s findings w/ a gallstone ileus? You may not necessarily be febrile. I would like to know this for my own knowledge.

I'll have to change my statement somewhat. A combination of normal RUQ U/S, normal abdominal x-ray (which MacGyver doesn't mention), and normal pancreatic enzymes makes gallstone ileus very unlikely. Here is my reasoning:

Normal RUQ U/S: Gallstone ileus is almost always due to erosion of a gallstone through the wall of the gall bladder into bowel (usually duodenum). This can be associated with acute gangrenous cholecystitis, which RUQ ultrasound rules out. It can also be due to chronic cholecystitis and cholelitiasis, which can be seen on US, but not as well. Either way, there should be some evidence of inflammation of the gallbladder, whether it be global or focally in the area of fistulization. This fistula can also cause pneumobilia, for which US is very sensitive. The fistula itself can be seen on US, but not reliably. So with a totally normal GB, the risk of this diagnosis is low, but still possible (espcially if study was limited by bowel gas.

Normal Abdominal X-ray. In order to have GB ileus there should be evidence of obstruction. Stone may or may not be seen. Pneumobilia can also be seen on x-ray, though it is less sensitive.

Normal pancreatic enzymes: Although extremely rare, a stone large enough to cause ileus can pass through common bile duct, especially if the patient has had a prior sphincterotomoy. A stone this large passing through would almost definitely cause pancreatitis.

 

[Masonator]

MacGyver I hate to pop you on ,but Hep A is fecal oral, not sexally transmitted. Acute Hepatitis is a possibility, as there is a subset in this group that develop sever myalgias with the onset of liver failure. What rules against this is the lack of jaundice in your description. Some Tbili and alkphos values would be great however. If you could elicit pain after eating, or abd pain way out of proportion to abd exam you could favor acute mesenteric ischemia. If he was ****ting blood from it that would imply necrotic bowel and probably would not resolve the way it did. Its too bad your information is second hand. This guy is probably not going to get a full work up unless his symptoms worsen again, so we may never know what happened.

 

[Kazu]

MacGyver I hate to pop you on ,but Hep A is fecal oral, not sexally transmitted.

I think MacGiyver said that given the patients sexual history the other hep viruses are unlikely and hep A, not being sexually transmitted, is more likely.

 

[Masonator]

I think MacGiyver said that given the patients sexual history the other hep viruses are unlikely and hep A, not being sexually transmitted, is more likely.

My bad. I didn't get the inference.

 

[MacGyver]

Yes, I was implying that Hep A is more likely than the other hep viruses, given his lack of sexual/blood contact.

They discharged him from the hospital, so apparently there were no specific findings that they could use to further direct diagnostic tests. All the hep tests came back negative.

How good is abdominal ultrasound at picking up small tumors in the gallbladder/pancreas/liver/stomach? I assume MRI is a lot better, but they didnt run an MRI or CT.

 

[maxheadroom]

I don't think MRI/CT are very good. The best test is endoscopic U/S.

 

[Masonator]

MacGyver how did you get two red squares for your karma? I only have a grey square. I'm so jealous.

 

[Whisker Barrel Cortex]

Ultrasound is great at picking up gall bladder tumors, pretty good at picking up liver lesions, sometimes OK at seeing the pancreas, and never used to evaluate the stomach (except endoscopic).

CT can actually be pretty good at evaluating the stomach, but not as good as endoscopy. It is great for picking up liver lesions and pancreatic lesions if IV contrast is used. Without IV contrast it is useless for this purpose. It is only OK for gallbadder, ultrasound is better.

MRI is not generally used for evaluation of the stomach. It is very good for evaluation of the liver. Pretty good for evaluation of the panreas and gallbladder. MRI needs to be tailored to small regions and does not give as good a general picture of the abdomen as CT. Information from MR is often complementary to info on CT, not mutually exclusive.

 

[Disenchanted 1]

MacGyver how did you get two red squares for your karma? I only have a grey square. I'm so jealous.

LOL masonator, here's some bad karma for you since you seem to be desperately striving to get some bad reputation around here!! You can thank me later baby.