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.
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CASE CONCLUSION: Surgery consulted, no emergent surgery recommended, admitted to medicine for observation
CASE LESSONS:
- Never
- Always