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Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017
| Contributor Information
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Images courtesy of Reginelli A, Iacobellis F, Berritto D, et al. BMC Surg. 2013;13 Suppl 2:S51. PMID: 24267670, PMCID: PMC3850956.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
In the United States, abdominal pain is among the most common symptoms that cause patients to visit the emergency department (ED). Unfortunately, it is often difficult to readily identify the precise etiology of gastrointestinal (GI) symptoms. A delay in diagnosis and treatment for many disorders may lead to an abdominal catastrophe. Can you diagnose potentially life-threatening conditions that present with GI symptoms?
An 82-year-old female with a history of untreated atrial fibrillation presents to the ED with abdominal pain after consuming dinner. She states that the abdominal pain is severe, yet physical examination shows a mildly tender abdomen without rebound or guarding. The blood lactate level is found to be elevated. The patient has had no prior abdominal surgeries. What is the likely diagnosis?
Pancreatitis
Acute mesenteric ischemia
Peptic ulcer disease
Bowel obstruction
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: B. Acute mesenteric ischemia
This patient has acute mesenteric ischemia, a condition that results from inadequate blood flow to vessels supplying the gut.
Embolic events account for roughly 50% of all clinical cases of acute mesenteric ischemia. In addition, atrial thrombi from atrial fibrillation, endocarditis, and plaques are commonly implicated.[1] Due to its higher flow rate and lower angle, the superior mesenteric artery is commonly affected (aortogram revealing narrowing of the superior mesenteric artery is seen above).[2]
On the previous slide, the computed tomography (CT) scan (left) demonstrates a case of acute venous mesenteric ischemia, showing mural thickening, peritoneal fluid, and mesenteric engorgement; the diagnosis was confirmed at surgery (right).
Acute mesenteric ischemia from an embolism often presents with a sudden onset of pain secondary to an acute occlusive event. Nausea and vomiting are common. Laboratory testing is nonspecific, and imaging in the form of a contrast-enhanced CT scan or angiogram is usually required.[3] Occlusive ischemia is generally treated surgically, and all patients who present with peritonitis warrant immediate surgical evaluation. Mesenteric ischemia is associated with a high mortality rate (75%).[4]
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 61-year-old man presents to the ED with right upper quadrant abdominal pain and fever. He denies experiencing nausea or vomiting. His medical history is notable for diabetes and coronary artery disease. On further questioning, he reports that he has experienced multiple self-limited episodes of abdominal pain. An abdominal radiograph is ordered (shown).
What critical disease process is identified on the radiograph?
Ischemic bowel
Ruptured abdominal aortic aneurysm
Emphysematous cholecystitis
Hydatid liver cyst
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: C. Emphysematous cholecystitis
Emphysematous cholecystitis is an infection of the gallbladder wall by gas-forming organisms.[5] It may be caused by vascular compromise of the gallbladder secondary to cholelithiasis, immunosuppression, or seeding from manipulation in a previous procedure.
The classic presentation is right upper quadrant pain and fever in a diabetic elderly man. Radiographs may demonstrate air within the gallbladder wall, as shown on the previous slide, which can be confirmed by CT imaging (shown).
Emphysematous cholecystitis, which is a surgical emergency, has a 15-20% mortality rate.[6]
Image courtesy of Søreide JA, Viste A. Scand J Trauma Resusc Emerg Med. 2011;19:66. [Open access.] PMID: 22035338, PMCID: PMC3219576.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 32-year-old man presents to the ED 90 minutes after an acute episode of vomiting, which caused him to have severe chest pain. The patient has an odor of alcohol on his breath. His friends state that the patient was "okay" before the vomiting episode. His blood pressure is 95/50 mm Hg. Electrocardiography (ECG) is performed and shows sinus tachycardia at 130 beats per minute without any ST-segment changes. The patient has an oral temperature of 99.9°F and an oxygen saturation of 98% on room air.
His chest radiograph is shown. What is the most likely diagnosis?
Acute myocardial infarction
Esophageal perforation (Boerhaave syndrome)
Left-sided empyema
Perforated gastric ulcer
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: B. Esophageal perforation (Boerhaave syndrome)
Boerhaave syndrome, a full-thickness perforation of the esophagus, classically occurs following a sudden, forceful episode of emesis after alcohol consumption.[7] This condition has a very high mortality rate and requires emergent surgical consultation.
The chest radiograph on the previous slide shows a leak of Gastrografin contrast material (short arrows) into the left posterolateral aspect of the pleural cavity, indicating esophageal perforation (the long, thin arrow on the previous slide points to a gastric tube). A left-sided pleural effusion is the most common radiologic finding in patients with Boerhaave syndrome. The pain associated with this syndrome is usually acute, severe, and located anywhere from the abdomen to the neck. Patients can quickly develop tachycardia, tachypnea, and hypotension that leads to shock. Mediastinitis may also occur; on chest auscultation, a "Hamman crunch" (a crackling sound that is typically coincident with each heartbeat) may be heard.[7]
Chest CT scan studies usually confirm the diagnosis of Boerhaave syndrome; they may also demonstrate a false tract originating from the esophagus (arrow).
Image courtesy of Moussaid I, Haddad W, Salmi S, et al. Pan Afr Med J. 2012;12:63. [Open access.] PMID: 23024822, PMCID: PMC3450925.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
An 81-year-old man with advanced Parkinson disease is transferred from a nursing home with a 1-day complaint of "crampy" abdominal pain. The pain is moderate and mostly in the left lower quadrant. The patient also states that his stomach appears more "bloated" than normal. He has a chronic history of constipation; his last bowel movement was 2 days ago. On physical examination, his vital signs are within normal limits, and there is moderate tenderness to palpation in the periumbilical area without guarding or rebound. The rectal examination does not reveal any stool.
His abdominal radiograph is shown. What is the most likely diagnosis?
Intussusception
Femoral hernia
Fecal impaction
Sigmoid volvulus
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: D. Sigmoid volvulus
On CT scan, dilation of the sigmoid (arrows) with a normal-appearing proximal colon can be seen. Bedridden patients and those with neuropsychiatric disorders are at greatest risk for having a sigmoid volvulus, because psychoactive drugs may slow gut motility.[8] Redundant sigmoid (ie, sigmoid elongation that results in a redundant loop) is also a risk factor.
Patients typically present with acute abdominal pain, cramping, distention, and constipation. Initial stabilization is with intravenous (IV) fluids and broad-spectrum antibiotics. Surgery is the definitive treatment in all unstable patients, but endoscopic decompression may be a suitable initial option for stable patients.[8]
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 50-year-old man presents to an urgent care center with acute-onset abdominal pain, fever, nausea, and vomiting. The symptoms began after he strained while having a bowel movement. Over the past few hours, the patient has developed a "big rash" over his abdomen (shown). His wife reports that he has been acting more confused since they left home. His history is notable for deep vein thrombosis, for which he is taking warfarin.
What is the most likely diagnosis?
Acute pancreatitis
Rectus sheath hematoma
Abdominal anaphylaxis
Incarcerated hernia
Image courtesy of Medscape | Dr David Gordon.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: B. Rectus sheath hematoma
Rectus sheath hematoma is typically caused by rupture of an epigastric artery or a muscular tear with shearing of a small vessel.[9] Severe trauma or exertion is usually the cause in patients with normal coagulation profiles; however, in anticoagulated patients, seemingly benign actions such as Valsalva maneuvers, coughing, or sneezing may be responsible for hemorrhage.
Hematomas may be difficult to palpate if they are posterior to the rectus abdominis muscle, but they should be readily identifiable on CT scans (arrow).[9] If the hematoma is not self-contained, it may continue to expand, leading to hemodynamic compromise. Affected patients may need anticoagulation reversals, transfusions, and surgical intervention.
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 60-year-old woman presents to an urgent care center with a complaint of profuse, foul-smelling, watery diarrhea and vomiting. Her symptoms have become progressively worse over the past 24 hours, and she reports a fever of 105°F. She denies having any significant medical history but reports that she was recently treated with ampicillin for "an infection." An abdominal radiograph is obtained, with the findings shown.
What is the disease process that is most likely affecting this patient?
Food poisoning
Mesenteric ischemia
Giardia infection
Pseudomembranous colitis
Image courtesy of Medscape | Dr Eric M Osgard.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: D. Pseudomembranous colitis
Pseudomembranous colitis is an acute inflammatory disease of the colon that is typified by loosely adherent mucosal exudates (shown).[10] Classic symptoms are large-volume diarrhea and fever in patients with recent antibiotic use.
Abdominal radiographs may demonstrate mucosal edema (as seen on the previous slide) and ileus, and these imaging studies are useful to rule out toxic megacolon. CT scans may show luminal distention, diffuse wall thickening, and pericolonic inflammation.[10] Severe cases may lead to the development of toxic megacolon or perforation; emergent bowel resection may be required in such cases.
Image courtesy of Kelly J, Corrigan M, Cahill RA, Redmond HP. World J Emerg Surg. 2007;2:9. [Open access.] PMID: 17448234, PMCID: PMC1868019.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 26-year-old man is brought into the ED by customs officials after being agitated and uncooperative during a security screening. You note that the patient is diaphoretic and has dilated pupils. The patient's vital signs are significant for a blood pressure of 180/90 mm Hg, a pulse of 124 beats per minute, a respiratory rate of 24 breaths per minute, and an oral temperature of 99.1°F. An abdominal radiograph is obtained, with the findings shown.
What is the most appropriate intervention?
Whole-bowel irrigation with polyethylene glycol
Surgical consultation
Emergent colonoscopy
Activated charcoal
Image courtesy of Wikimedia Commons | Kelly J, Corrigan M, Cahill RA, Redmond HP. World J Emerg Surg. 2007;2:9. [Open access.] PMID: 17448234, PMCID: PMC1868019.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: B. Surgical consultation
This case depicts a "body packer" who ingested packets filled with drugs (asterisks) to smuggle them through customs. Management of an asymptomatic packer can consist of whole-bowel irrigation with polyethylene glycol followed by imaging (upper GI series or CT scan) to confirm full removal.[11]
Because the patient is showing signs of intoxication, most likely from cocaine, immediate surgical consultation is necessary. Toxicity and death quickly ensue in the event of packet rupture. Benzodiazepines should be administered liberally [11] as the patient is prepared for immediate laparotomy.
Image from Wikimedia Commons | Dr. James Heilman.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 60-year-old man presents with crampy abdominal pain, nausea, vomiting, and a low-grade fever. He has had episodes like this in the past, and they have usually subsided within a few days. On physical examination, there is left lower quadrant tenderness to palpation without evidence of rebound or guarding. A CT scan of the abdomen/pelvis with contrast reveals the principle abnormality (circled).
What is the most common potentially devastating complication seen in association with this disease process?
Fistula formation
Upper GI bleeding
Colon cancer
Pancreatitis
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: A. Fistula formation
The patient has diverticulitis. CT scan findings include fat stranding, diverticula, and bowel-wall thickening (as shown on the previous slide).[12] Fistulas and abscess formation are common complications of diverticulitis.
A barium enema study may identify fistula formation. The above image reveals a colovesical fistula, which is demonstrated by contrast medium filling the bladder (arrow). Patients with fistula formation are at risk for severe infections and typically require surgical intervention.
Image courtesy of Medscape | Dr Ademola Adewale.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 53-year-old man presents to the ED with 24 hours of abdominal pain and three episodes of nausea, vomiting, and diarrhea. The patient describes the pain as intermittent and crampy. He has lost all appetite and has not had a bowel movement in 3 days. His surgical history includes cholecystectomy and appendectomy. His physical examination is notable for hyperactive bowel sounds. His abdominal radiograph is shown.
What is the most likely diagnosis?
Pancreatitis
Gallstone ileus
Small-bowel obstruction
Toxic megacolon
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: C. Small-bowel obstruction
The most common cause of small-bowel obstruction is adhesions after abdominal surgery; other common causes are incarcerated hernias, malignancy, Crohn disease, gallstone ileus, and radiation enteritis.[13] Patients typically present with crampy, intermittent abdominal pain; nausea; vomiting; and diarrhea.
Abdominal radiographs reveal dilated small-bowel loops with air-fluid levels on upright or decubitus views and a decompressed distal bowel.[13] Closed-loop obstructions or strangulated bowel (arrow) are surgical emergencies with high untreated mortality rates.
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 32-year-old man presents to the ED with a 10-hour history of abdominal pain, malaise, nausea, and anorexia. The patient states that the pain is generalized to his periumbilical region, but it has recently migrated to the right lower quadrant. Physical examination of the abdomen reveals tenderness in the right lower quadrant without evidence of rebound tenderness or involuntary guarding. The patient is afebrile with a normal white blood cell count.
An abdominal CT scan with oral and IV contrast media is shown. What is a common complication of the patient's condition?
Glomerulonephritis
Inflammatory bowel disease
Abscess formation
Liver failure
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: C. Abscess formation
This patient has appendicitis, which is typically caused by obstruction of the appendiceal lumen by a fecalith.[14] Obstruction with ongoing mucosal secretion increases intraluminal pressure, which eventually surpasses the vascular pressures and leads to ischemia and perforation. The resulting peritoneal inflammation produces pain that is localized to the "McBurney point."
CT imaging is usually able to readily identify an enlarged appendix with surrounding fat stranding (shown).[15] Patients with appendicitis require appendectomy because a delay in treatment can lead to rupture and/or abscess formation.[14]
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 78-year-old woman with arthritis presents to the ED with an acute onset of abdominal pain, nausea, and vomiting. She admits that emesis has been red-tinged. Physical examination of the abdomen reveals diffuse tenderness with rebound and involuntary guarding. The patient is tachycardic.
An upright chest radiograph is taken, with the findings shown. What is the likely diagnosis?
Gastroenteritis
Diaphragmatic hernia
Perforated ulcer
Pericarditis
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: C. Perforated Ulcer
This patient has pneumoperitoneum, a complication of perforated ulcers in patients with peptic ulcer disease. The perforated ulcer allows air to enter the abdominal cavity,[16] as seen on the radiograph on the previous slide and on the CT scan above.
Peptic ulcer disease typically occurs as a result of either Helicobacter pylori infection, drugs (commonly, nonsteroidal anti-inflammatory drugs [NSAIDs]), genetic factors, lifestyle factors, severe physiologic stress, or hypersecretory states.[17]
This patient likely developed an NSAID-induced ulcer, which perforated. The incidence of perforation is approximately 0.3% per patient-year of NSAID use.[16] Emergent surgical management is required; surgery for peptic ulcer perforations is associated with a 6-30% mortality rate.[18]
Image courtesy of Seshadri P, Dev AV, Viggeswarpu S, Sathyendra S, Peter JV. Malar J. 2008 May 30;7:97. doi: 10.1186/1475-2875-7-97. PMID: 18510778. PMCID: PMC2426706.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
A 41-year-old man with a history of weekend binge drinking presents to the ED with an onset of dull, sharp abdominal pain that has now begun radiating to his back. He notes that the pain is worse with any intake. The patient has a heart rate of 110 beats per minute. On physical examination, the patient's abdomen is soft, with moderate epigastric tenderness and muscular guarding. There is no rebound.
A CT scan is performed, with the findings shown. What is the likely diagnosis?
Pancreatitis
Perforated ulcer
Hepatitis
Diverticulitis
Image from Medscape.
Can't-Miss Gastrointestinal Diagnoses
Chris Bryczkowski, MD; Raffi Kapitanyan, MD, FACEP | September 13, 2017 | Contributor Information
Answer: A. Pancreatitis
This patient has pancreatitis, a state of inflammation and autodigestion of the pancreas. Alcohol use accounts for at least 35% of cases, and together, alcohol use and biliary tract disease account for 60-80%. Other causes include trauma, medications, and infections, although up to 30% of cases are idiopathic.[19] On the CT scan seen on the previous slide, the presence of acute pancreatitis is indicated by the bulky pancreas (white arrow) and peripancreatic fat stranding (black arrow).[20]
Medical management of mild acute pancreatitis includes IV hydration and oral intake restriction. Severe cases may include shock and multiorgan system failure, requiring intensive care.[21] Acute pancreatitis has an overall mortality rate of 10-15%, but this can rise to about 30% in severe cases. [22]
Other complications of pancreatitis include fluid collections and infections. Pancreatic pseudocyst formation in chronic pancreatitis usually takes 4 weeks; chronic pancreatitis can also include pancreatic calcifications (both are demonstrated on the CT scan above, with the arrow pointing to the pseudocyst).[21,23]
As the US population demographics change, clinicians need to be familiar with variations in the prevalence, clinical presentation, and treatment of dermatologic disease in people with skin of color. Learn how to recognize and manage various lesions on skin of color.Slideshows, August 2017
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Contributor Information
Authors
Chris Bryczkowski, MD
Assistant Professor
Interim Chief, Division of Emergency & Critical Care Ultrasound
Director, Emergency Ultrasound Fellowship
Department of Emergency Medicine
Rutgers-Robert Wood Johnson Medical School
New Brunswick, NJ
Disclosure: Chris Bryczkowski, MD, has disclosed no relevant financial relationships.
Raffi Kapitanyan, MD, FACEP
Partner at Brunswick Urgent Care
East Brunswick, NJ
Disclosure: Raffi Kapitanyan, MD, FACEP, has disclosed no relevant financial relationships.
Editor
Lars Grimm, MD, MHS
Assistant Professor
Department of Diagnostic Radiology
Duke University Medical Center
Durham, NC
Disclosure: Lars Grimm, MD, MHS, has disclosed no relevant financial relationships.
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References
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Cappell MS. Intestinal (mesenteric) vasculopathy. I. Acute superior mesenteric arteriopathy and venopathy. Gastroenterol Clin North Am. 1998 Dec. 27(4):783-825, vi. PMID: 9890114
Dang CV, Su M, Nishijima DK. Acute mesenteric ischemia. Medscape Drugs & Diseases from WebMD. Updated December 27, 2016. Available at: http://emedicine.medscape.com/article/189146-overview. Accessed September 1, 2017.
Safioleas MC, Moulakakis KG, Papavassiliou VG, Kontzoglou K, Kostakis A. Acute mesenteric ischaemia, a highly lethal disease with a devastating outcome. Vasa. 2006 May. 35(2):106-11. PMID: 16796010
Sunnapwar A, Raut AA, Nagar AM, Katre R. Emphysematous cholecystitis: imaging findings in nine patients. Indian J Radiol Imaging. 2011; 21(2):142-6. PMID: 21799598
Roy PK, Murphy ME, Kalapatapu V, Bashir S, Mujibur R. Boerhaave syndrome. Medscape Drugs & Diseases from WebMD. Updated July 6, 2015. Available at: http://emedicine.medscape.com/article/171683-overview. Accessed September 1, 2017.
Svanes C, Lie RT, Svanes K, Lie SA, Soreide O. Adverse effects of delayed treatment for perforated peptic ulcer. Ann Surg. 1994;220(2):168-75. PMID: 8053739 [Full text].
Whitcomb DC, Yadav D, Adam S, et al. Multicenter approach to recurrent acute and chronic pancreatitis in the United States: the North American Pancreatitis Study 2 (NAPS2). Pancreatology. 2008;8(4-5):520-31. PMID: 18765957 [Full text].
Seshadri P, Dev AV, Viggeswarpu S, Sathyendra S, Peter JV. Acute pancreatitis and subdural haematoma in a patient with severe falciparum malaria: case report and review of literature. Malar J. 2008 May 30;7:97. PMID: 18510778 [Full text].
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