Abdominal pain in a young woman

Problem 13 Abdominal pain in a young woman



Peter Devitt




A 28-year-old woman presents to the emergency department with upper abdominal pain. The pain starts in the epigastrium and radiates to the right and left upper quadrants. She rates the pain as 7 out of 10. She has had several similar episodes over the last 6 weeks. During each episode, the pain was of rapid onset and resolved spontaneously after several hours. On each occasion she was nauseated but did not vomit. She is significantly overweight with a body mass index of 36.



Q.1


What further information would you like from the patient? What are the possible diagnoses?


The patient is otherwise in good health with an unremarkable medical history. She is considerably distressed by the pain, but the physical examination is normal apart from some tenderness in the right upper quadrant. She is overweight with a BMI of 34. Arrangements are made for her admission.



Q.2


What investigations does this patient require?


An ultrasound examination of the upper abdomen is performed (Figures 13.1 and 13.2).


image

Figure 13.1


image

Figure 13.2


There is bilirubin + on urinalysis. Her serum biochemistry is shown below.



Investigation 13.1 Summary of results

image


Q.3


What do the investigations show?


The day after admission the patient is feeling much better and is pain-free.



Q.4


What is the appropriate advice to give the patient?


Her liver function tests are improving. She listens to your advice and agrees to a plan of ERCP followed by elective cholecystectomy. Her weight has not previously been mentioned as a problem. Should it be added to the introduction if it is used her? She is discharged home with arrangments for an ERCP the following week.


Five days later you are asked to see the patient in the emergency department. She has had further bouts of pain on and off for 2 days and has vomited a number of times. She also reports that her urine has darkened and that her stools are pale. She has not slept well the past 2 nights because of drenching sweats and she reports two violent shivering attacks this morning. She is uncertain of the date or day.


On examination she looks ill, distracted and has a temperature of 39.5°C. She is flushed and has yellow sclera. Her pulse is 110 bpm and her blood pressure is 90/50 mmHg. She has dry mucous membranes. Examination of her cardiorespiratory system is unremarkable. Her abdomen is soft and there is no localized area of tenderness.



Q.5


State the diagnosis and describe an appropriate plan of management.


With prompt resuscitation the patient improves and an ERCP is performed once she is stable. In preparation for this procedure, informed consent must be obtained.



Q.6


What risks would you inform the patient of when seeking consent?


The ERCP is performed and the image shown in Figure 13.3 is obtained.


image

Figure 13.3



Q.7


What does the image show?


The patient makes a rapid recovery from her illness and her liver function tests return to normal. She is discharged home, manages to lose 20 kg and subsequently undergoes an elective laparoscopic cholecystectomy.



Answers


A.1 Further information must be sought on:


• The pain:
– its nature (constant or colic)

– radiation (round or through to the back, retrosternal, shoulder, down into abdomen)

– its severity, did it disturb her normal activities, her sleep or stop her going to work

– any relieving or exacerbating features.

• Any associated urinary or gastrointestinal symptoms.

• Any evidence of biliary obstruction during these episodes such as overt jaundice (friends and family may notice), pale stools and dark urine.

• Any past history of gastrointestinal or renal tract problems.

These severe episodes of right upper quadrant pain requiring opiate analgesia are characteristic of biliary colic (stones in the gallbladder or bile duct). The pain will often radiate around the costal margin to the back. Biliary colic may result from obstruction of the cystic duct, which typically occurs when a gallstone becomes impacted in Hartmann’s pouch. The pain – which is typically unremitting and constant – lasts until the gallstone falls back into the gallbladder and the obstruction is relieved.


Other diagnoses to consider include:


• Renal stones or ureteric colic. Stones in the renal tract can produce severe upper abdominal and back pain.

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Apr 2, 2017 | Posted by in GENERAL SURGERY | Comments Off on Abdominal pain in a young woman

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