A Daily Beer Drinker With Agonizing Gas and Back Pain

Erik D. Schraga, MD


February 09, 2021


Transverse cuts obtained from CT of the abdomen and pelvis (Figures 1 and 2) showed free air underneath the diaphragm consistent with a perforated viscus. The images also demonstrated fluid in the region of the distal antrum/pylorus, with a small pocket of air in this fluid, suggesting that the stomach was the site of the perforation. The patient's history of alcohol use pointed to a diagnosis of a perforated gastric ulcer.

Figure 1.

Figure 2.

In the differential diagnosis of epigastric abdominal pain, several life-threatening etiologies that must be recognized and treated urgently are possible. Cardiovascular causes, including acute coronary syndrome and aortic dissection, must be considered, even when frank chest pain is absent. Numerous gastrointestinal causes can present in a very similar fashion. Most commonly, a relatively benign cause, such as mild esophagitis or gastritis, is responsible. The pain of an uncomplicated peptic ulcer is similar that of a perforated peptic ulcer, although it is typically chronic.

Gallbladder disease ranges from relatively mild biliary colic to acute cholecystitis. Liver diseases include acute hepatitis; masses, such as abscesses or tumors; gonococcal or chlamydial perihepatitis (Fitz-Hugh-Curtis syndrome) in women; and acute cholangitis. Acute pancreatitis may be present, with or without gallbladder disease. Acute appendicitis may first present with upper abdominal or mid-abdominal pain before localizing to the right lower quadrant.

Pulmonary processes, such as pneumonia, must also be considered in patients with upper abdominal pain, even in the absence of cough or shortness of breath.[1]

With such a broad differential diagnosis, the workup for epigastric abdominal pain (including laboratory investigations and radiologic imaging) must be individualized on the basis of age and other risk factors for each potential disease process and on the characteristics and associated symptoms of the pain. In addition, assessment of the symptoms and physical examination should be repeated during the course of the evaluation.

The administration of parenteral pain medication often enables localization of the source of pain and assessment of the severity of the disease. Pain medication should not be withheld for fear of "masking" a potentially serious disease process. As illustrated in this case, the patient had somewhat vague examination findings and an essentially normal initial workup, including no evidence of perforation on an upright radiograph at presentation; this may have been dismissed as "benign" pain if it were not for the persistence of pain and tenderness despite the administration of pain medication.


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