Wierd Case, any ideas

[roja]

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80ish yo female, increasing diffuse abdominal pain x 1 day now constant. +nausea. 180s/60s, 60, 100% RA

BKA secondary to 'poor circulation
'abdominal surgery' secondary to adhesions

PE remarkable for soft belly with diffuse severe abd pain. Heme pos brown stool. became more 'peritoneal' as the hour went on...

CXR: neg for free air. no PNA
EKG: severe LVH. 1mm st depressions anterior lateral.. unchanged
CT with IV contrast: one area of regional enteritis. No AMI, no obstruction, no diverticulitis


This peanut of a lady (maybe 90 lbs) was eating through 24 mg of MSO4 and still her belly is killing her.

WBC 13
Lactate 3.0
Trop 0.03
LFTs nl
Lipase 18
CPK nl

Signed her out and she was still in pain and was screening her into the ICU. Been driving me crazy all day.....

any other ideas?

 

[applicant2002]

Bowel/mesenteric ischemia?

 

[Blue Dog]

Bowel/mesenteric ischemia?

That's what I was thinking.

 

[rayoflite]

what does her aorta look like?

 

[ERMudPhud]

That sounds like a textbook presentation for ischemic/dead gut

1. vasculopath
2. pain out of proportion to fairly benign exam with heavy narcotic needs
3. regional bowel edema (in vascular distribution?)
4. mildly elevated serum lactate

I realize its July but please tell me the surgical consult didn't just blow her off

 

[southerndoc]

Bowel/mesenteric ischemia?

It would be a stuttering type ischemia since her lactate was only 3. One day's worth of ischemia should give you a more impressive lactate than 3.

Out of curiosity, was this an arterial or venous lactate? If it was a venous lactate, what was the tourniquet time?

 

[roja]

See CT results. She had a normal aorta and no evidence of mesenteric ischemia. No obstruction
It was read by an attending radiologists.. no obstruction to flow (2mm cuts on the ct.)

venous lactate... tourniquet time was quick as I did hte iv myself.

 

[ERMudPhud]

See CT results. She had a normal aorta and no evidence of mesenteric ischemia. No obstruction
It was read by an attending radiologists.. no obstruction to flow (2mm cuts on the ct.)

venous lactate... tourniquet time was quick as I did hte iv myself.

Attendings are doing the IV's? I see things haven't changed at SLR in the last 10 years

I still think she has vascular insufficiency until an angiogram or exlap rules it out. What did the attending surgeon think?

 

[roja]

Agreed with the radiologist and resident (they did think she was peritoneal-ish)

Only did the IV because she was a hard stick and I had sent the nurse to get morphine. I like to occasionally put in iv's and keep my skills up. I am an anomoly in that I will put in IV's and draw blood when things are crazy or if I am not doing much. Most of our attendings probaby couldn't tell you the last time they put an iv in.

I am still convinced that its in her belly as well. Nothing else makes sense... just wanted to see if I was not thinking of some wierd rare thing....

 

[jetproppilot]

80ish yo female, increasing diffuse abdominal pain x 1 day now constant. +nausea. 180s/60s, 60, 100% RA

BKA secondary to 'poor circulation
'abdominal surgery' secondary to adhesions

PE remarkable for soft belly with diffuse severe abd pain. Heme pos brown stool. became more 'peritoneal' as the hour went on...

CXR: neg for free air. no PNA
EKG: severe LVH. 1mm st depressions anterior lateral.. unchanged
CT with IV contrast: one area of regional enteritis. No AMI, no obstruction, no diverticulitis


This peanut of a lady (maybe 90 lbs) was eating through 24 mg of MSO4 and still her belly is killing her.

WBC 13
Lactate 3.0
Trop 0.03
LFTs nl
Lipase 18
CPK nl

Signed her out and she was still in pain and was screening her into the ICU. Been driving me crazy all day.....

any other ideas?

Diverticulitis.

 

[Dimoak]

Agreed with the radiologist and resident (they did think she was peritoneal-ish)

Only did the IV because she was a hard stick and I had sent the nurse to get morphine. I like to occasionally put in iv's and keep my skills up. I am an anomoly in that I will put in IV's and draw blood when things are crazy or if I am not doing much. Most of our attendings probaby couldn't tell you the last time they put an iv in.

I am still convinced that its in her belly as well. Nothing else makes sense... just wanted to see if I was not thinking of some wierd rare thing....

Hey, I'm no expert, but did you exactly rule out diverticulitis? If so, did you guys also check for any sort of hepatic obstructions or weird erosions in the GI tract? Maybe you should also consider giving her some Mag/Alum/Simethicone; her numbers may just be a bit deceiving overall due to her age. Just my 2 cents, for whatever they're worth.

 

[docB]

The CT should have shown something if it was diverticulitis with a WBC of 13. Does PO contrast help any more? My understanding is that with the new 10 zillion slice scanners it's obsolete. Was this done on the hot new machine or the old dusty back up CT? If it was I feel for you. We blew a tube on the good CT and were reduced to the old 16 slice for several hours the other night. It then overheated and we were without CT for about 4 hours .

I suppose this could also have been something really weird like porphyria or black widow bite.

 

[ERMudPhud]

Most of the studies are small but the bottom line is that sensitivity for ischemia on CT ranges from about 75% to 100%. Unfortunately to get a 100% sensitivity they had to include very nonspecific things like focal bowel edema and do CT angio with multidetector scanners. Here are two reviews

: McLeod R, Lindsay T, O'Malley M; Evidence Based Reviews in Surgery Group.
Canadian Association of General Surgeons and American College of Surgeons
evidence based reviews in surgery. 15. Biphasic CT with mesenteric CT
angiography in the evaluation of acute mesenteric ischemia: initial experience.
Can J Surg. 2005 Dec;48(6):491-3. No abstract available.
PMID: 16417057 [PubMed - indexed for MEDLINE]

2: Segatto E, Mortele KJ, Ji H, Wiesner W, Ros PR.
Acute small bowel ischemia: CT imaging findings.
Semin Ultrasound CT MR. 2003 Oct;24(5):364-76. Review.
PMID: 14620718 [PubMed - indexed for MEDLINE]

Black widow bite is a great thought but I think they are a lot more common in Las Vegas than in NYC. In NYC I think they got driven away by the giant roaches. I doubt her first presentation of porphyria was at age 90.

Make sure you give us the follow up

 

[roja]

1. new scanner. (see above, cuts were 1-2mm) they saw a small plaque in the SMA but had flow everywhere in the mesentary. No diverticulitis.

2. Pt signed out ama this morning apparantly. so now I will never know.

 

[MedicinePowder]

1. new scanner. (see above, cuts were 1-2mm) they saw a small plaque in the SMA but had flow everywhere in the mesentary. No diverticulitis.

2. Pt signed out ama this morning apparantly. so now I will never know.

bowel ischemia. she must've been the small percentage of peeps that pass the ct with flying colors even though their gut is in the early process of rottenin.

 

[sarahinromania]

What was her glucose?

 

[roja]

nl

 

[docB]

nl

Possibly the shortest yet legitimate and substantive reply ever. Way to go.

 

[GeneralVeers]

Possibly the shortest yet legitimate and substantive reply ever. Way to go.

Kidney stones, pyelo? Always check a UA on old people.

 

[roja]

Urine dip was negative. UA negative. CT remember, was negative. No pyelo. No stones