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Cirrhotic epigastric pain

UnFiNiShEd CaSe CoMe BaCk LaTeR

History of Present Illness:

A man in his 60’s with a history of diabetes, cirrhosis and gallstones presents to the ED with 2 weeks of “RLQ pain radiating to the back” per triage along with constipation and now 2 days of vomiting.  He denies any fever, bleeding, melena or other complaints

Vital Signs & Physical Exam:

Vital signs are normal except for a pulse of 101.   Physical exam is otherwise normal except for epigastric but not RLQ tenderness

Initial Diagnostic Testing:

  • CBC: normal except for 79% PMNs
  • Chem 7: normal except for sodium of 128.  LFT’s mildly elevated
  • Imaging: A CT scan is done

What is the diagnosis?

  • A) SBO
  • B) LBO
  • C) fistula
  • D) pneumobilia
  • E) gallstone ileus

SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT

 

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ANSWER:

  • A) SBO: not present but there is an ileus
  • B) LBO: Possibly.  Stone is near the splenic flecture in the large bowel
  • C) fistula: CORRECT – see arrow
  • D) pneumobilia: CORRECT – see arrow
  • E) gallstone ileus: CORRECT – see gallstone in left upper colon.  Usually if obstruction will be in terminal ileum so unclear if this is an obstruction or an ileus.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: Surgery consulted, no emergent surgery recommended, admitted to medicine for observation

CASE LESSONS:

  1. Never
  2. Always
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