Abdominal Pain, Anemia, and Oliguria in a Distressed Woman

Eva Nourbakhsh, MD; Kenneth M. Nugent, MD; Rishi Raj, MD

Disclosures

April 30, 2021

Physical Examination and Workup

Upon physical examination, the patient is in distress secondary to her abdominal pain. She is hypotensive, with a blood pressure of 73/45 mm Hg, and tachycardic, with a heart rate of 180 beats/min. No fever is noted (temperature, 98.9°F [37.2°C]). Her oxygen saturation is 97% on 2 L/min. Her head, neck, and pulmonary examination findings are all normal. The heart rate is rapid and periodically irregular, but no jugular venous distention or peripheral edema is detected.

She has abdominal wall bruising from enoxaparin injections. The abdomen is firm and diffusely tender to palpation, without rebound or guarding, and hypoactive bowel sounds are noted. On neurologic examination, an unchanged chronic left hemiparesis is found. The rest of the physical examination is unremarkable.

A complete blood count and metabolic panel reveal leukocytosis (28.1 kU/L), anemia (hemoglobin level, 7.3 g/dL; hematocrit, 21.1%), hyperkalemia (serum potassium, 5.9 mmol/L), renal insufficiency (creatinine level, 1.6 mg/dL; blood urea nitrogen, 32 mg/dL; estimated glomerular filtration rate, 32 mL/min/1.73 m2), and an anion gap metabolic acidosis (carbon dioxide level, 15 mmol/L; anion gap, 23 mEq/L). Her liver enzymes are mildly elevated, with an alkaline phosphatase level of 126 IU/L, an alanine aminotransferase level of 73 IU/L, and an aspartate aminotransferase level of 129 IU/L.

Her prothrombin time is 18.2 sec, correlating with an international normalized ratio of 1.62. The cardiac enzymes include a total creatinine kinase (CK) level of 21 IU/L, CK-MB isoenzyme level of 1.8 ng/mL, and troponin-t level of 0.19 ng/mL.

Electrocardiography (ECG) shows atrial fibrillation with a rapid ventricular response but no evidence of acute ischemia. Chest radiography does not reveal any acute disease process. CT scanning of the abdomen and pelvis reveals a large 15 cm x 13 cm hypodense mass posterior to the left rectus abdominis muscle, with dependent hyperdensities and a collapsed inferior vena cava (Figure 1; Figure 2).

Figure 1.

Figure 2.

The patient is immediately placed on a cardiac monitor, and a 500-mL normal saline bolus is administered; slight improvement is seen in both her heart rate and blood pressure. Because of this, medical management is continued rather than emergent cardioversion. A Foley catheter is placed, but no urine output is seen. After a second and third 500-mL bolus, the blood pressure remains low, but the heart rate has dropped to 129 beats/min. A diltiazem drip is initiated for control of her atrial fibrillation.

During the first 24 hours of intensive therapy, she receives a total of 4250 mL of normal saline, 3 units of packed red blood cells, and 4 units of fresh frozen plasma. Norepinephrine is started for persistent hypotension despite fluid and blood resuscitation. At this point, the patient's abdomen is noted to be somewhat tense and more painful, so an intra-abdominal pressure (IAP) measurement is performed and is found to be 24 mm Hg. A consultation with the surgery department is ordered, and supportive measures are continued. Six hours later, the IAP has increased to 38 mm Hg.

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