Recurrent Abdominal Pain With Abdominal Distention

A 70-year-old woman presents to the emergency department (ED) with progressive abdominal pain (this is her second presentation; she recently presented to the ED with similar complaints). Over the last few years, she has experienced multiple short periods of abdominal pain that always resolve spontaneously a few hours after taking over-the-counter analgesics or with the administration of intravenous analgesics, bowel rest, intravenous fluid, and supportive treatment at visits to her primary care provider and other medical venues. At these previous visits, all laboratory and radiologic investigations have always been unremarkable, and the patient has always been discharged to home. At this visit, as a result of an increase in the intensity of the abdominal pain and the development of mild distention, it is decided to admit her to the hospital. She is noted to have 2 episodes of vomiting and a normal bowel movement while in the ED. Her past medical history is remarkable for insulin-dependent diabetes and hypertension, for which she is on antihypertensive medications. She also takes daily aspirin. She underwent a laparoscopic cholecystectomy 15 years ago, but there is no other history of surgery.

On physical examination, her oral temperature is 98.6°F (37.0°C), her pulse rate is 94 bpm, and her blood pressure is 168/92 mm Hg. Overall, she is noted to be uncomfortable secondary to colicky pain. The head and neck examination is normal. Her lungs are clear when auscultated, with normal respiratory effort, and her heart examination is normal except for occasional premature ventricular beats. On abdominal examination, there is some fullness of the epigastric and left upper quadrant regions, with mild tenderness on deep palpation. The rest of the abdomen is soft, with no abnormal pigmentations. Small scars from the previous laparoscopic cholecystectomy are noted. Rectal examination is unremarkable. There is no edema in the extremities.

The laboratory investigations show an elevated blood glucose level of 140.54 mg/dL (7.8 mmol/L; normal range, 75-115 mg/dL), but otherwise the patient is noted to have a normal extended metabolic panel, including lipase and liver enzymes, and a normal complete blood count (CBC), with no evidence of leukocytosis or anemia. A urinalysis is negative for blood, nitrites, and leukocytes. Plain abdominal radiographs show a nonspecific bowel gas pattern (not shown) and no signs of bowel obstruction. The patient is transferred to the hospital floor for bowel rest, intravenous fluids, and antiemetics. On hospital day 2, she is noted to be in increasing pain; a general surgery consultation is requested and abdominal computed tomography (CT) scan is performed (see Figures 1 and 2).

What is the cause of the patient’s abdominal pain and distention?

Hint: Look carefully at the bowel loops.

a.

a.Acute splenic injury

b. pancreatitis

c.Left paraduodenal hernia

d.Cecal volvulus

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Filed Under: Discussion • GI

Tags: Acute splenic injury, Cecal volvulus, Left paraduodenal hernia, pancreatitis