Sudden LUQ Pain*
History of Present Illness:
A man in his early 50’s presents to the emergency department for sudden onset of LUQ abdominal pain. He denies any vomiting, diarrhea or other complaints.
Vital Signs & Physical Exam:
Vital signs are normal except for a pulse of 111.
Physical exam is otherwise normal except for epigastric tenderness without guarding
Initial Diagnostic Testing:
- EKG: normal
- Labs: normal including lactic acid
- Imaging: CT shown below
What is the most likely diagnosis?
- Gastritis
- Pancreatitis
- Gallstones
- None of the above
SCROLL DOWN FOR ANSWERS & 1-MINUTE CONSULT
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ANSWERS:
- Gastritis: can show up on CT, thought rarely unless severe. This cut does not show the stomach.
- Pancreatitis: not seen on CT
- Gallstones: can cause epigastric pain but LUQ pain would be very unusual. This cut does not show the gallbladder.
- None of the above: CORRECT. The image shows a SMA dissection. It is not easy to see and was actually missed by the first radiologist. A coronal view is shown below with a white line as an indicator. The SMA is to the lower right of the dashed line. There is a flap in the middle of it
1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook
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CASE CONCLUSION: Patient was admitted, seen by vascular surgery and started on aspirin & Xarelto. He remained stable and was discharged after 24 hours.
CASE LESSONS:
- Always remember there are sometimes Zebras, especially when the clinical presentation doesn’t fit more common conditions. The sudden onset of pain was a clue here, as was the unexpected CT finding:)
- Never underestimate the importance of luck, but also that luck favors those who work hard.