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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?

  1. Gastritis
  2. Pancreatitis
  3. Gallstones
  4. 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:

  1. 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:)
  2. Never underestimate the importance of luck, but also that luck favors those who work hard.
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