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Abdominal Pain and Vomiting 50 Year Old Male
Introduction : Initial Complaint
Patient describing his abdominal pain:
"Doctor, this pain I’m getting is excruciating. It is the worst pain that I have ever had.
It started yesterday and it is just not going away.
It’s just awful and I think I’m getting a temperature."
Check Vitals :
Heart rate : 90 bpm
Blood Pressure : 140/85 mm hg
Respiratory rate : 20 rpm
Oxygen saturation : 95 %
Temperature : 101.3 degree Fahrenheit / 38.5 degree Celsius
Height / Weight : 172 cm / 90kg
Case Presentation :
Patient describing his abdominal pain: Further questioning / History taking
"It used to happen for short episodes but never anything like this. Sometimes I get it here, right under my ribs but it always goes away after a few hours (patient pointing to his epigastrium/RUQ).
This time it’s getting worse and worse. It’s like a knife sticking in to me and it’s shooting around into my back.
I feel very nauseated and I have vomited a few times.
No matter what I do, I can’t get comfortable."
Background / Patient History
Past Medical History:
Diet controlled diabetes mellitus (see other in Systems Review for details)
Hypercholesterolaemia and on medications for 3 years
No history of myocardial infarction or stroke
Past Surgical History:
Undescended testis as a child
Ankle fracture 20 years ago - ORIF
Social and Family History
Social History:
Lives with wife and two children
Two children both in University
Works as a bank manager
Non-smoker
Social drinker, < 21 units per week
No recent travel
Family History:
Sister has diabetes - type 2
Both parents still alive
Mother has atrial fibrillation
Father has prostate cancer
His own children are well
Medications and Allergies
Medications:
Omeprazole 20mg po OD (orally, once daily)
Atorvastatin 10mg po OD
No known drug allergies
Systems Review
Eyes, ears, nose and throat
No blurring of vision, coryza or rhinorrhoea
Cardiac
No exertional chest pain
No palpitations or syncope
Good exercise tolerance
No history of cardiac disease
No MI
Respiratory
No history of respiratory disease
No history of asthma, COPD
With this episode of abdominal pain , he is finding it hard to catch his breath
Gastrointestinal
Gastrointestinal history as per presenting complaint:
Epigastric pain, severe, radiating to back yesterday
Came on gradually after breakfast yesterday
Severe, colicky in nature initially. Now constant for more than 12 hours
No relieving factors although he felt a little better after vomiting
Tried antacid tablets but vomited the tablets
Made worse by lying still - feels better pacing around
Was unable to sleep at all last night
Associated with nausea and vomiting (bilious)
No haematemesis
No melaena
Has a 3 month history of episodic right upper quadrant colicky abdominal pain, associated with eating rich food but it usually resolves
No change in bowel habit or blood per rectum
No urinary symptoms
No jaundice
Felt a little hot and sweaty
Genitourinary
No dysuria, frequency or haematuria
No flank or loin-to-groin pain
Neurological
Non-contributory
Musculoskeletal
Non-contributory
Dermatological
No jaundice or itch
Vascular
Is diabetic but well controlled and has no intermittent claudication, TIA, stroke, hypertension or foot ulceration
Bleeding and clotting history
No history of abnormal clotting or bleeding - has had dental extractions without a lot of bleeding
Other
Diabetic history (from clinical notes):
Type 2 diabetes x 4 years
Diet controlled
Good control- recent lipids and HbA1c were within normal range
Well educated and monitors his own sugars
No retinopathy - undergoes routine retinal screening
No peripheral neuropathy - attends chiropodist regularly
No history of ischaemic heart disease, hypertension or stroke
No hypertension
No impotence
Hypercholesterolaemia - on statin
No history of peripheral vascular disease
No history of foot ulceration
No history of recurrent skin infections
On Examination
General Inspection
Patient distressed and in obvious discomfort
Lying in bed and turning from side to side
High BMI - 30.4kg/m2
Orientated to person, place and time
No jaundice or cachexia
No rashes
Looks a bit diaphoretic
Cardiovascular & Respiratory
Cardiovascular:
Pulses normal and regularly, regular
Capillary refill time < 2 seconds
No palpable thrill or heave
Heart sounds 1 + 2 normal
No added sounds or murmurs
JVP is not raised
Respiratory:
Decreased breath sounds at both bases but taking very shallow breaths
Resonant to percussion
No crepitations or wheeze
Gastrointestinal & Genitourinary
Difficult examination due to body habitus - obese abdomen and not comfortable lying down
Abdominal distension secondary to increased adiposity
Soft on palpation with no guarding
Tenderness in the right upper quadrant
Pain exacerbated by inspiration
No rebound tenderness
Positive Murphy's sign
No palpable masses or organomegaly
Normal bowel sounds
Digital rectal exam unremarkable
FOB negative
Normal external genitalia
Neuromuscular & Limbs
Normal tone, power and coordination limbs
Cranial nerves 1 - 12 intact
Normal cerebellar exam
Appropriate speech and comprehension
Absent ankle reflexes bilaterally
Decreased light touch sensation in feet
Pedal pulses normal
Callouses on MTP joints great toes bilaterally
No ulceration
Nails thickened
MANAGEMENT
A.Initial Management - Airway & Breathing
This patient has presented with severe epigastric pain radiating to his back.
He is finding it hard to catch his breath with a respiratory rate of 20 rpm and oxygen saturations of 95% in room air.
He is obese.
What are the most appropriate airway and breathing management options in his case?
a.Administer 2 litres oxygen via nasal prongs
Oxygen should be given via nasal prongs for patient comfort.
His saturations are low and he is tachypnoeic with reduced air entry at both bases.
b.Sit the patient upright
The patient should sit upright for comfort. He has a high BMI and is in pain so his inspiratory effort is poor. Encouraging him to sit up may help to improve his oxygen saturations.
B.Initial Management - Circulation & Fluids
The patient is alert with no melaena or haematemesis. His heart rate is 90 bpm and his blood pressure is 140/85 mmHg
What are the most appropriate circulation and fluid management options in his case?
a.Insert a peripheral intravenous cannula (PIC)
The patient is vomiting and pyrexic, he will require replacement fluids, antibiotics and analgesia intravenously. A large-bore peripheral intravenous cannula should be sited to allow the administration of intravenous fluids and medication as required.
b.Commence IV rehydration and maintenance fluids
This gentleman should remain fasting due to his ongoing vomiting, therefore he maintenance intravenous fluids should be commenced.
c.Keep fasting
This gentleman should be placed nil by mouth.
He is vomiting and has severe abdominal pain so fasting is required for patient comfort and to rest his gut and also because operative management may be required.
C . Initial Management - Disability
This man is in a lot of pain and is very uncomfortable. He is clinically stable with a tender abdomen.
Plan treatment and procedure will make him more comfortable?
Antiemetics
Prochlorperazine may relieve nausea and vomiting.
In this case, use the intramuscular route regularly.
A nasogastric tube
If the patient has copious bilious vomiting, a nasogastic can give great relief and make the patient more comfortable.
Opioid analgesia
There is some debate about using morphine due to its effects on the sphincter of Oddi but opioid analgesia can be a very effective analgesic when administered parenterally.
Intravenous fluids at a rate of 100 - 125ml/hour
This man is pyrexic and has been vomiting.
Keeping him fasting, inserting a nasogastric tube and commencing him on intravenous fluids will help to make him more comfortable.
Initial Investigations
Initial Investigations - Bedside Investigations
What bedside investigations should be requested for this patient to help your diagnosis?
a. Arterial Blood gas
An arterial blood gas should be performed in unwell dyspnoeic and potentially septic patients.
This will provide immediate haemoglobin, potassium and lactate levels as well as an indication of both respiratory and acid-base statuses.
b.Dipstick Urinalysis
Urinalysis is a simple bedside test which can be used to out rule urinary tract infection as a cause of pyrexia, pyelonephritis and renal calculi.
If positive, urine should be sent to the microbiology lab for culture.
c.Electrocardiogram (ECG/EKG)
This patient is unwell with borderline tachycardia therefore electrocardiogram should be performed.
Also, in a diabetic patient, cardiac chest pain can present atypically and myocardial infarction should be out-ruled.
d.Fingerprick glucometer
This man is diabetic - he should have his glucose level measured.
Initial Investigations - Haematology
Which of the following investigations should be requested from the haematology laboratory?
a.Full blood count / Complete blood count
A full blood count should be performed to assess for elevated white cell count which may indicate infection.Coagulation screen (aPTT, PT & INR)
b.Coagulation screen (aPTT, PT & INR)
The patient presents with right upper quadrant pain which may be secondary to a liver pathology, and liver dysfunction may result in abnormal coagulation.
Also, the patient is unwell and may require operative intervention and a baseline coagulation screen is required prior to this.
c.HbA1C
This gentleman has a history of diet controlled diabetes mellitus, HbA1c should be performed to assess baseline glycaemic control.
Initial Investigations - Biochemistry
HIs fingerprick glucometer reading is within normal range.
Which of the following investigations should be requested from the biochemistry laboratory?
a.Urea and electrolytes / Renal profile
This gentleman has poor oral intake, therefore urea and electrolytes should be performed to assess level of dehydration and renal function.
b.Liver function test (LFTs)
Liver function may be abnormal if there is a hepatobiliary cause of abdominal pain such as choledocholithiasis.
Alanine aminotransferase (ALT) and aspartate aminotransferase (AST) levels may be elevated in cholecystitis or with common bile duct obstruction.
Bilirubin and alkaline phosphatase assays are used to evaluate evidence of common duct obstruction.
An elevated alkaline phosphatase level is observed in 25% of patients with cholecystitis.
c.Cardiac Enzymes
This gentleman has epigastric pain and significant cardiac risk factors, including diabetes mellitus, which can result in atypical presentations of myocardial infarction (such as with abdominal pain).
C-reactive protein (CRP)
C-reactive protein should be performed as it is a marker of inflammation and may indicate an infectious cause of this presentation.
d.Blood Glucose
Blood glucose should be closely monitored in any diabetic patient who is unwell.
e.Lactate
The patient has cardiovascular risk factors and his severe abdominal pain may be secondary to an ischaemic insult.
Ischaemia causes elevated serum lactate.
He is also pyrexic and lactate levels are part of a sepsis work-up.
It is also possible to rapidly assess lactate levels by performing a venous or arterial blood gas.
f.Amylase
Amylase should be performed to evaluate for pancreatitis in any unwell patient presenting with severe abdominal pain and in particular when they have a backgrond history of what sounds like biliary colic.
g.Troponin
This man is diabetic and cardiac ischaemia can present in unusual ways in diabetic patients.
Initial Investigations - Microbiology
His dipstick urinalysis reveals 1+ glucose and 1+ protein.
investigations, if any, should be requested from the microbiology laboratory?
a.Blood culture
This patient is unwell with pyrexia, therefore blood cultures should be performed as part of a septic screen.
b.Sputum culture (if sputum is being produced)
This patient is unwell with pyrexia, therefore sputum cultures should be performed as part of a septic screen, particularly in the setting of dyspnoea and reduced air entry bibasally.
c.Urine culture
This patient is unwell with pyrexia, therefore urine cultures should be performed as part of a septic screen.
Initial Investigations - Radiology
What radiological investigations should be requested for this patient?
a.Chest radiograph
This man has decreased air entry both lung bases and is finding it hard to catch his breath which may be due to poor inspiratory effort and obesity but he should have a chest radiograph performed to evaluate this further.
An erect chest radiograph will also look for free air under the diaphragm as a result of perforation of a viscus.
b.Abdominal ultrasound
An abdominal ultrasound should be performed as it is a non-invasive test that can quickly diagnose intra-abdominal pathology and is very good for imaging the liver, gallbladder and common bile duct.
It is the most appropriate radiological investigation in this case.
c.Consider a CT abdomen
Ultrasound is the first line test.
CT is a secondary imaging test that can identify intra- abdominal pathology such as extrabiliary disorders and complications of acute cholecystitis, such as gangrene, gas formation, and perforation.
Results - Hematology
Full Blood Count / Complete Blood Count
Test Result Units Range US Result
US Units
US Range
White cell count
15.0 x 10^9/L
( 4 – 10 )
15.0 x 10^3/μL
( 3.9 - 11.7 )
RBC 4.7 x 10^12/L
( 4.5 - 5.5 )
4.7 x 10^6/μL
( 4.2 - 6.4 )
Haemoglobin 15.6 g/dL ( 13.5 – 18.0 )
15.6 g/dL ( 13.5 - 18.0 )
Haematocrit 0.43 L/L ( 0.36 – 0.46 )
43 % ( 41 - 51 )
MCV 90 fL ( 84 – 96 )
90 fL ( 80 - 97 )
MCH 29 pg ( 27 – 32 )
29 pg ( 26 - 34 )
MCHC 32.7 g/dL ( 31.5 - 34.5 )
32.7 g/dL ( 32 - 36 )
Platelet Count
450 x 10^9/L
( 150 – 400 )
450 x 10^3/μL
( 150 – 400 )
Neutrophils 13.2 x 10^9/L
( 2 – 7 ) 13.2 x 10^3/μL
( 1.5 - 8.0 )
Lymphocytes 1.8 x 10^9/L
( 1 – 3 ) 1.8 x 10^3/μL
( 0.8 - 4.0 )
Coagulation Screen
Test Result Units Range US Result
US Units
US Range
Prothrombin Time
11.2 seconds ( 10.2- 12.0 )
11.2 seconds ( 11 - 13 )
INR 1 1
APTT 26 seconds ( 23 – 30 )
26 seconds ( 25 - 35 )
Courtesy : American college of physicians ( ACP Guidelines )
Results - BiochemistryUrea & Electrolytes / Renal Profile
Test Result Units Range US Result
US Units
US Range
Sodium 138 mmol/L ( 135 – 138 mEq/L ( 136 - 145 )
145 )
Potassium 4.2 mmol/L ( 3.5 – 5.0 )
4.2 mEq/L ( 3.5 - 5.1 )
Chloride 105 mmol/L ( 94 – 110 )
105 mEq/L (98 - 107 )
Urea 10 mmol/L ( 2.9 - 8.2 )
28 mg/dL ( 8 - 20 )
Creatinine 110 μmol/L ( 62 – 106 )
1.24 mg/dL ( 0.7 - 1.3 )
eGFR 63 ml/min ( 60 – 160 )
63 ml/min ( 60 – 160 )
Glucose 6.5 mmol/L ( 3.9 - 7.8 )
117 mg/dL ( 70 - 130 )
Liver Function Test
Test Result
Units Range
US Result
US Units
US Range
Total Protein
76 g/L ( 64 – 83 )
7.6 g/dL ( 6.4 - 8.3 )
Albumin
47 g/L ( 39 – 51 )
4.7 g/dL ( 3.5 - 5.0 )
Total Bilirubin
15 μmol/L
( 1 – 19 )
0.88 mg/dL
( 0.1 - 1.2 )
ALP 76 U/L ( 35 – 104 )
76 U/L ( 53 - 128 )
AST 32 U/L ( 0 – 40 )
32 U/L ( 10 - 50 )
ALT 70 U/L ( 0 – 70 U/L ( 10 -
40 ) 35 )
GGT 150 U/L ( 6 – 42 )
150 U/L ( 2 - 30 )
Miscellaneous Biochemistry
Test Result
Units Range
US Result
US Units
US Range
C Reactive Protein
20 mg/L ( 0 – 5 )
20 mg/L ( 0 - 5 )
Lactate
1.2 mmol/L
( 0.6 – 1.6 )
1.2 mmol/L
( 0.5 - 2.2 )
Amylase
50 U/L ( 28 – 100 )
50 U/L ( 0 - 130 )
Creatine Kinase
75 U/L ( 26 - 195 )
75 U/L ( 30 - 170 )
Troponin T
10 mg/L ( 0 - 14 )
0.001
ng/mL
( < 0.03 )
Courtesy : American college of physicians ( ACP Guidelines )
Results - Chest Radiograph
Upright chest radiograph showing poor differentiation of both right and left hemidiaphragms consistent with bibasal atelectasis.
No focal consolidation.
No hyperinflation.
No signs of congestive heart failure.
Results - Abdominal Ultrasound
Cholelithiasis in combination with the sonographic Murphy sign.
Both gallbladder wall thickening (>3 mm) and pericholecystic fluid are present.
Results - Dipstick Urinalysis
Mid-Stream Urine
Test Result
Ketones ( + )
Glucose ( + )
Protein ( + )
Leucocytes ( - )
Nitrates ( - )
Blood ( - )
Results - Arterial Blood Gas
Arterial Blood Gas (Room Air)
Test Result Units Range US Result
US Unit
US Range
pH 7.41 ( 7.35 - 7.45 )
7.41 ( 7.35 - 7.45 )
pCO2 5.3 kPa ( 4.7 - 6.0 )
39.8 mmHg ( 34 - 46 )
pO2 12.5 kPa ( 10.6 - 13.0 )
93.8 mmHg ( 80 - 100 )
HCO3 24.7 mmol/L ( 22.0 - 26.0 )
24.7 mEq/L ( 23 - 28 )
Sa02 96 % ( 95 - 100 )
96 % ( 95 - 100 )
Base Excess
1 mEq/L ( -2 - +2 )
1 mEq/L ( -2 - +2 )
Diagnosis
This man presents with severe constant central/RUQ abdominal pain and pyrexia. He is normotensive.
He is tachypnoeic with elevated WBC count (15), normal glucose, pH and lactate.
He does not fulfil sepsis criteria.
What is the most likely diagnosis in this case?
Acute cholecystitis
Acute cholecystitis is most likely considering the background history of right-sided upper quadrant pain radiating to the back and exacerbated by fatty food (biliary colic).
This acute cholecystitis episode is confirmed by raised temperature, abdominal tenderness, raised inflammatory markers and an abdominal ultrasound that shows cholelithiasis, pericholecystic fluid and gallbladder wall thickening >3mm.
Bibasal atelectasis is also seen on chest x-ray which is likely secondary to reduced chest expansion because of pain and obesity.
Differential Diagnosis
a.Peptic ulcer disease with possible perforation
The patient has a long standing history classical for biliary colic, and now presents with similar symptoms in conjunction with raised inflammatory markers and ultrasound findings consistent with acute cholecystitis.
In peptic ulcer disease you would expect to see evidence of free air under the diaphragm on erect chest radiograph and a history of gastritis would be more commonly observed in this setting. The abdomen is often tense with both guarding and rigidity present on examination.
b.Pancreatitis
This patient's pain is predominantly right-sided, with no epigastric tenderness as would be expected with acute pancreatitis. In addition, his serum amylase is normal. A normal amylase can occur in chronic pancreatitis but his acute presentation and history is not consistent with this diagnosis.
c.Pyelonephritis
Pyelonephritis is unlikely as there is no evidence of infection on urinalysis and he does not have renal angle tenderness on examination and there are no strong signs of infection on urinalysis.
d.Biliary colic
Biliary colic presents as colicky abdominal pain that lasts less than 6 hours and is not usually associated with vomiting. LFTs are not usually abnormal.
This man reports having episodes of what sounds like biliary colic over the last 3 years but his presentation now is different and more sever with constant pain that is diagnostic of cholecystitis
Treatment Plan - Admission & Treatment
a.Admit under the care of a gastroenterology team
This gentleman requires admission for analgesia, antiemetic and antibiotic therapy.
He should have a surgical review +/- surgical intervention.
b.Request a surgical review
This gentleman may require surgical management therefore a surgical opinion should be arranged
c.Conservative management
If the patient improves clinically, with resolution of pain and temperature, he can be discharged home with out-patient follow up.
Elective cholecystectomy may be arranged following discharge.
Pre-operative MRCP may be indicated to ensure there are no stones present in the common bile duct.
If this patient were to deteriorate during this admission and there was a diagnosis of sepsis, then urgent surgical intervention should be considered.
In patients who are very unwell or septic consider ascending cholangitis as the diagnosis. Patients will often have a bacteraemia with positive blood cultures.
A stone In the common bile duct will cause biliary obstruction leading to biliary dilatation, jaundice and in some cases, pancreatitis.
These patients require emergency stone removal or stent insertion.
Treatment Plan - Intervention
The patient is reviewed by the surgeons and admitted and they are happy for him to be treated conservatively.
What interventions and treatments should the patient receive to aid in his recovery?
a.Co-amoxiclav 1.2g iv TDS (intravenously, three times a day)
The administration of IV antibiotics are preferred in this setting, after sending off blood cultures if possible.
The patient should be treated with intravenous antibiotics because he is pyrexic and systemically unwell.
Co-amoxiclav is first line therapy.
Blood cultures can take up to 72 hours to return with definitive result.
If a specific bacteria is cultured and the laboratory has the sensitivities, antibiotic treatment should be tailored appropriately.
b.Opioid analgesia - pethidine
For opioid analgesia in acute cholecystitis pethidine is preferred to morphine.
This is because morphine can cause an increase in tone of the sphincter of Oddi. An anticholinergic spasmodic such as dicyclomine can also help reduce pain.
c.Low molecular weight heparin (LMWH)
Venous thromboembolic (VTE) prophylaxis should be commenced in this patient - LMWH and compression stockings. He is at risk of venous thromboembolism because he is overweight, diabetic and has an infection.
d.Thromboembolic deterrent (TED) stockings
Venous thromboembolic (VTE) prophylaxis should be commenced in this patient.
Graded compression stockings should be applied. Stockings below the knee are sufficient and generally more comfortable for patients.
e.Chest physiotherapy
The patient should receive chest physiotherapy and incentive spirometry to treat his atelectasis and prevent the development of a pneumonia.
