Mysterious Epigastric Pain
Chief Complaint – Acute Onset Epigastric Pain for 2 hours
HPI: 32 year old, previous healthy, AAM, who presents to the ER with 2 hours of acute onset epigastric pain. Reports some nausea. Denies fever, chills, vomiting, diarrhea, belching, new foods, melena, and hematochezia. Denies SOB, chest pain, cough, sick contacts, or rash.
PMH: None
PSH: None
Allergies: NKDA
Medications: None
SH: Occ Alc
FH: Non-significant
Physical Exam
Vitals – BP 120/80, HR 90, RR 18, SaO2 99%, 99.5 F
HEENT – wnl
CV – RRR, no murmur
Respiratory – CTA, equal air entry, no w/r/r/
Abdominal – Moderate epigastric tenderness, positive bowel sounds, soft, no guarding, no murphys sign, no mcburneys point tendernss, no hernia
Extremities – no tenderness, swelling, erythema
Neuro – Gross motor/sensation intact
Skin – No rash
Labs
CBC – wnl
CMP – wnl
Lipase – wnl
Lactic Acid – wnl
UA – wnl
Imaging
AAS – wnl
Discussion
This patient is a healthy male who presents to the ER with 2 hour acute onset epigastric pain. The patient has physical exam that supports gastritis, unremarkable vital signs, and unremarkable labortatory values.
This patient’s symptoms were relieved with a intravenous dose of morphine and Pepcid. The patient’s ER course was unremarkable, and the patient remained stable at all times. The attending requested a CT ABD/Pelvis w/ IV contrast for further evaluation of the patient’s complaint.
CT Abd/Pelvis Result : Acute appendicitis with perforation.
This patient was referred to the surgical service and taken to the OR later on that afternoon.
Teaching Point
This patient presented with low suspicion based on HPI, and physical exam for appendicitis. However, this case taught me to be cautious and be sure to rule out emergencies before considering a patient stable for discharge. In this patient, without CT Abd/Pelvis, there was not thorough evaluation for appendicitis which represents an acute intra-abdominal emergency. Missing acute appendicitis is also a common reason for ER malpractice cases.
This case changed my way of practicing. Potentially, all patients who present with abdominal pain should be evaluated for the known life-threatening emergencies of the abdomen before being considered stable for discharge:
- Ruptured AAA
- Acute Appendicitis
- Acute Cholecystitis
- Acute Pancreatitis
- Small Bowel Obstruction
- Obstructing Urolithiasis
- Diverticulitis
- Intestinal Perforation
- Mesenteric Ischemia
- Diabetic Ketoacidosis
- Acute Cholangitis
- Incarcerated Hernia
- Pyelonephritis
- GI Bleed
St John E-shift Blog 
So I have to say that I totally disagree with the decision to CT this patient, and I would have 100% sent this patient home. I realize this means I would have missed the dx, but (unless something is not being represented accurately in the H+P), I see no reason to CT this guy. Are we to CT everyone with completely normal labs and trivial abdominal pain that is now resolved? What are people’s thoughts on this?
I completely agree. No way would I have gotten a ct, and I would have sent him home. And I think that would be defendable. Yes we need to think about every life threatening diagnosis but then you rule it out. And I would say this guy’s clinical presentation would lead you to a non-life threatening diagnosis a million times out of a million and one. Your attending just got lucky and that’s it.
I like to entertain the notion that I get to think critically at work, using my physical exam, labs, imaging, and ever-growing clinical gestalt to calculate both objective and subjective PPV/NPV for further testing and intervention. The ol’ Hail Mary CT Abd/Pelvis + Contrast (TM) certainly has a frustrating place in our practice as I’ve recently learned but that’s when things aren’t adding up (pain out of proportion, unstable VS, etc.). I find absolutely no indication to order a CT based on the patient presented and I would bet there are at least 10 pts discharged every day that would fit the pre-test profile presented. Sometimes, just because pathology is found, doesn’t necessarily mean it should have been. Required disclaimer: thankfully it was found in this case, given life-threatening findings.
With all due respect, I believe that there must be something missing from the patient presentation given above. For example, how could the AAS be normal and the patient be pain free?Further, if there isn’t anything missing then I would not have ordered a CT scan either. That being said, there are some things to learn from this case. First of all, appendicitis is included in my differential of any young male with anorexia. The typical presentation is an 18 yr old boy with no appetite/nausea and abdominal pain. Do you know how much 18 yr old boys eat?! Unless there is significant diarrhea or an obvious history of something like binge drinking/ sick contacts, one must consider appy. Also, look for signs like a pulse out of proportion to patient’s age and level of distress. My favorite is the tympanic temp of 99.5 and HR of 115. Usually that indicates a fever underestimated by our thermometers. Finally, as some of the residents know and loathe, I am liberal in giving patients early appy instructions upon discharge when an appy is unlikely but hasn’t been ruled out completely. I feel that a conversation with the patient/ parent about what to look for goes a long way in multiple regards.
Thanks
HB
My opinion is that D/C with good f/u instructions would’ve been adequate in this case, as suspicion for ruptured appy is very low. I do think that the threshold for ordering advanced tests should be lower when something just doesn’t seem right, however. This was acute onset pain in someone previously healthy, not sounding like more typyical insidious GERD pain. I would definitely consider a perforated ulcer, which wasn’t mentioned in this case. The AAS, however, was ordered and didn’t show anything.
With low suspicion, I’d argue overall harm of testing would exceed the benefits in this case good practice would’ve excluded a CT.