Polite Dissent

I thought I’d talk about medicine for a post or two. Not “television medicine” or “comic book medicine”, but real honest to God medicine.

Abdominal pain is the topic of choice today. This is one of those complaints that every doctor loathes. Mostly because it can include everything from a mild stomach upset to a surgical emergency and you have little idea what you’re in for until you peruse the chart and actually take a look at the patient. In addition, the physical exam is rarely as clear cut as you’d like. Plus if it’s a female patient, you’ve just doubled the number of possible diagnoses.

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The patient was a female in her late 50s complaining of right lower quadrant abdominal pain. Her past medical history was generally unremarkable except for some mild depression that was well controlled on a low dose of Lexapro. Her surgical history consisted of a tonsillectomy as a child, and the removal of a right-sided tubo-ovarian abscess about 10 years ago.

She presented with three days of slowly increasing abdominal pain. She described it as a crampy pain, 6 out of 10 on the pain scale. While the pain was always present, it waxed and waned in intensity. It was at its worst in her right lower quadrant, but she could feel some pain everywhere in her abdomen. She denied any radiation of the pain to the back, flank, or chest. There were no aggravating or alleviating factors. She denied any nausea or vomiting. She denied any diarrhea — in fact she mentioned that she had not had any bowel movements for three days, and no flatus either.

On exam, she was in moderate distress from the abdominal pain. Vital signs were normal; there was no fever. Abdominal exam revealed a non-distended abdomen with generalized tenderness. The pain was worst in the right lower quadrant, just under her old surgical scar. There was no rebound or guarding. There were no bowel sounds on auscultation.

My main concern at this time was a small bowel obstruction. Patients with bowel obstructions generally have more nausea and vomiting associated with them, but the rest of the symptoms fit, as did her history of prior abdominal surgery.

An acute abdominal x-ray series was obtained. The x-rays showed a couple of small air fluid levels in the small bowel and dilated bowel in the right lower quadrant. TWhile the x-ray was consistent with a small bowel obstruction, it was certainly not a smoking gun. An ileus would have a similar appearance on x-ray. (An ileus occurs when the bowel stops its normal peristaltic movements because of irriation, such as from an infection or a recent surgery)

I remained suspicious of a small bowel obstruction, likely related to adhesions from her previous surgery. I was also concerned about the possibility of an appendicitis with an overlying ileus, but appendicitis usually involves fever and nausea. The rest of the differential diagnosis included diverticular disease, cholecystitis, gastroenteritis, pancreatitis, mesenteric adenitis, or severe constipation. The patient was sent for stat labs and a stat CT scan.

The labs showed an elevated white cell count of 21,000 (normal would be 4,000 – 10,000) with a definite left shift. The other labs (including a BMP, LFT, amylase, lipase, and urinalysis) were all normal. The lab tech did inform me that the patient had an episode of vomiting while waiting for her labs to be drawn. These results were more suggestive of an infectious cause, but an elevated white count with a left shift can be seen in small bowel obstructions as well.

The CT scan showed no evidence of bowel obstruction. What it did show was a nasty appendicitis with a resultant ileus. The patient was taken to surgery and has done very well post-operatively. This patient was the perfect example of why doctors create a differential diagnosis. Nobody is correct all the time; my initial suspicion was shown to be wrong — but the next one on my list was the correct diagnosis. Sometimes the actual diagnosis is way down the list (this seems particularly true in cases of abdominal pain).

Note: This anecdote is very closely based on an actual patient. Some details have been changed to protect anonymity.

Tags: medicine abdominal pain bowel obstruction appendicitis