From the Blogosphere
Left Field Diagnosis
Eric Yazel, MD
W
orking over at Clark, very hectic
night shift. 42yo WF presents,
complaint is left flank pain, radiating to the front of her abdomen. She is in the
process of moving to Jeffersonville from New
Jersey and the pain started halfway en route. Episodic and colicky
in nature. Nausea, no vomiting. Normal stool pattern.
Day 3 - WBC back up to 23, pain increased, flat and upright films
show air in the bowel. Surgery consulted, original CT re-reviewed,
suspicion for thrombus in SMA. Operative exploration confirms,
patient undergoes excision of virtually her entire small bowel, right
colon, and proximal transverse colon with a jejunacolic anastamosis.
Uncomplicated post-op course, eventually transferred up to Indy
for eval for possible small bowel transplant.
PMH- high cholesterol; Surg-Tubal, doesn’t smoke drink or do
any drugs.
A few interesting issues here: first, after discussion with the radiologists, most older generation CT scanners cannot demonstrate
celiac trunk perfusion on routine contrasted CTs. The newer scanners can evaluate with much greater accuracy, but X-ray docs still
recommend that if mesenteric ischemia is high on your differential,
ask them specifically to evaluate the celiac trunk.
On exam, uncomfortable: restless in bed, can’t find a good position. Pain mostly localized to left flank, no reproducible anterior
abd tenderness, rest of exam is benign.
I order standard labs, urine, CT stone protocol and move on to
the next set of festivities.
Labs start to trickle in, I see a negative HCG and normal electrolytes, so off to CT she goes. Until I notice her CBC slide by-WBC
22.9 with 18 bands. Uh Oh. Maybe not a simple kidney stone. I’m
debating my no contrast CT now with that. She literally is on the
table so I have them go ahead and add IV contrast.
A few minutes later, I get a call from the radiologist-area of poor
perfusion to the left kidney. Suspicion is for severe pyelo vs renal
abscess. Odd, but at least I am thinking I have an explanation for the
leukocytosis and bandemia. Then the UA results come in-normal.
Completely. Nothing. At this point I really am pretty stumped as to
what is going on. I add on a couple blood cultures, lactic acid and
dose broad spectrum antibiotics. Discuss with the hospitalist, we
admit, urology consulted, repeat labs and exam in the am.
Hospital Course
The next day, WBC down mildly to 19, only one band. Patient
states she is feeling better.
Day 2 - pain is increasing WBC at 13 K, no stool output.
Also, now that we have moved from performing every CT abdomen with oral contrast, its awfully easy to order all as “IV only”
when presented with the prolonged disposition time that comes
with forcing an already nauseated patient to choke down oral contrast. Would it have helped in this case? Possibly: oral contrast in
mesenteric ischemia eval does help differentiate between worrisome
bowel wall thickening vs non-opacified bowel loops.
Third-Mesenteric ischemia is difficult to diagnose. The classic
finding is pain out of proportion to exam. What made this case
difficult was the presentation mimicking a kidney stone. Serum
lactate is classically the go-to test in board scenarios, but recent
studies show it’s got limited utility and has performed with no more
sensitivity than an elevated white count. As with coronary disease,
due