A 33-year-old male from South Asian presents with acute abdominal pain and several weeks of constipation. He had undergone cholecystectomy 2 months ago for similar symptoms with some resolution of the pain. He now presents with nausea, vomiting, and pain localized to the epigastrium. His laboratory test results are significant for hemoglobin of 8 µg/dL and white blood cell count of 9 µg/dL. He reports taking Ayurvedic home remedies.
What additional tests should be considered to diagnose the cause of his acute abdomen?
Correct Answer: A
Ayurvedic medications are known to contain heavy metals and in particular lead, and many of these remedies have been associated with lead poisoning. The acute abdomen has a multitude of causes. Many require surgical intervention, but some are related to medical conditions including endocrine, hematologic, and toxins including lead poisoning. It is important to elicit travel, medication, and work history. It is also important to consider environmental endemic conditions affecting the local community that the patient may be unaware such as the presence of lead paint or contaminated water supply.
A 28-year-old male who is an avid outdoorsman presents approximately 2 weeks after a hike in New Hampshire to the emergency department with severe abdominal pain. He is hypotensive with a distended abdomen. He denies recent trauma or falls. The focused assessment with sonography for trauma (FAST) is positive on the left for free fluid around the spleen. An exploratory laparotomy reveals a ruptured spleen.
What is the MOST likely explanation for his presentation?
Correct Answer: D
Spontaneous rupture of the spleen is rare and is usually caused by a discrete pathology such as malaria, Ebstein-Barr virus or other disorders associated with splenomegaly. Babesiosis is relatively common in the northeastern United States and is also known as “Nantucket fever.” Its incidence continues to rise in this part of the country. Splenic rupture has been reported more often in men with babesiosis, and this population tends to be healthy without previous trauma. Spleen conservation can be attempted in this population if they remain hemodynamically stable. Diagnosis is by blood smear or PCR. Treatment includes either atovaquone plus azithromycin or clindamycin plus quinine. Antibiotic management should be guided by an infectious disease specialist.
A 34-year-old morbidly obese male with a past medical history of intravenous drug abuse, HCV, lymphedema, and obstructive sleep apnea has now been in the intensive care unit (ICU) for 2 weeks for acute respiratory failure secondary to sepsis from a soft tissue infection. He develops a new fever with associated hypotension requiring vasopressor support. On physical exam he is intubated and sedated, with coarse breath sounds that are unchanged; however, an increase in peak airway pressures are noted, and his abdominal exam is notable only for severe obesity.
What imaging study would you request NEXT?
In this scenario, there is an acute decompensation in a critically ill patient. He is now hemodynamically compromised making CT imaging challenging, but not impossible. In most cases, it is usually easy and faster to obtain plain radiographs. They are extremely helpful in detecting free air. The three-view abdominal radiographs include an upright chest film, upright abdominal film, and supine abdominal film. The chest film is helpful in this patient as it will detect evidence of pneumonia, effusion, or ARDS, but can be detect as little of 1 mL of free air below the diaphragm. Abdominal radiographs can identify abnormal calcifications such as appendicoliths or gallstones, but they are less sensitive in establishing these diagnoses. They are more helpful in diagnosing gastric outlet obstruction, bowel obstruction, or large bowel volvulus. Owing to the ease and efficiency, plain radiographs would be the preferred next imaging obtained as it diagnosed this patient’s free air and expedited the time to operative intervention.
A 63-year-old obese female undergoes a robotic low anterior resection for rectal cancer, which goes well. On postoperative day 7, it is noted that she has become somnolent and febrile. You are called bedside to evaluate her for an ICU admission. On examination, she is lethargic and tachypneic with clear breath sounds. Her abdomen is mildly distended with moderate pain on palpation. Her vitals reveal her:
In addition to the standard septic workup including chest radiograph and culture data, you NEXT proceed to:
Correct Answer: B
This patient is 7 days after surgery, which makes the differential for sepsis quite wide. Important thing to consider is presence of lines or catheters. Other things to evaluate are the presence of drains. Risk factors for anastomotic leaks remain debated, but obesity, preoperative radiation, and lower rectal anastomoses are generally accepted risk factors. Pelvic drains can be placed intraoperatively, and this is a point of contention in the literature as far as their utility. There is some evidence of intraoperatively placed drains, which may in fact be a risk factor for anastomotic leaks. If they are present, the color and character can be helpful especially in the above clinical situation when purulent, feculent, or grossly blood output is noted. In the above scenario, anastomotic leak should be high on the differential and imaging should be obtained urgently.
Two weeks after a Whipple procedure, a 66-year-old male presents to the emergency department with severe abdominal pain. On evaluation, he is in moderate distress and is obviously uncomfortable. His vitals are notable for tachycardia of 120 bpm and hypotension with systolic blood pressure of 95 mm Hg. He is afebrile. A FAST reveals free fluid in all quadrants. Blood transfusion of blood products are initiated and his blood pressure responds to resuscitation.
The NEXT best management option is:
Correct Answer: C
Major hemorrhage after pancreaticoduodenectomy is uncommon, but is associated with a high mortality. Gastroduodenal stump pseudoaneurysms are the most common site of bleeding. They are classified based on timing of presentation. Early hemorrhage can occur 24 hours after surgery, and immediate return to the operating room is the typical management of choice. This is usually the result of a technical failure. Delayed hemorrhage can occur days to weeks after initial surgery and is thought to be due to erosion of vessels by biliary or pancreatic leaks. Typically this type of bleeding is best managed by interventional radiology.
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