Cramplike Pain and Vomiting in a 77-Year-Old Man

James J. McCombie, MB ChB; Erik D. Schraga, MD

Disclosures

March 28, 2017

Physical Examination and Workup

Upon examination, the patient is lying quite still. He does not appear cachectic, but does seem clinically dehydrated. His heart rate is 80 beats/min, his blood pressure is 102/65 mm Hg, his capillary refill time is prolonged, and cool extremities are noted. He is afebrile. His lungs are clear to auscultation and his heart sounds are normal, with no added sounds.

Figure 1.

Figure 2.

His abdomen is mildly distended, without visible scars, and there is no discoloration of the skin. When asked to cough, the patient winces in pain. No hernias are appreciated on examination. Palpation of the abdomen reveals generalized, diffuse tenderness and boardlike rigidity. The abdomen is tender to percussion throughout all four quadrants, with a tympanitic note that is associated with loss of liver dullness. A rectal examination reveals a small amount of normal stool. Both femoral pulses are palpable and equal. The neurologic examination reveals no abnormalities. The peripheral examination is normal except for cool extremities.

A fluid challenge of 500 mL 0.9% saline is given along with analgesia, and the patient's vital signs improve. Laboratory investigations yield the following:

  • White blood cell count: 15.8 × 103 cells/µL

  • C-reactive protein level: 247 mg/L

  • Sodium level: 148 mEq/L

  • Potassium level: 3.1 mEq/L

  • Urea level: 28.6 mg/dL

  • Creatinine level: 1.5 mg/dL

Blood gas analysis reveals a pH level of 7.31, an bicarbonate level of 20 mEq/L, a PCO2 of 4.1 kPa, and lactate level of 23.4 mg/dL.

Erect chest and supine abdominal radiographs are obtained (Figures 1 and 2). A nasogastric tube is inserted, and instructions are given for the patient to remain "nil by mouth." He is catheterized, and urinary output is monitored along with the vitals. A further 1000 mL of 0.9% saline is initiated. Cefuroxime and metronidazole are started intravenously, and after urgent surgical consultation, the patient is taken to the operating room for emergency laparotomy.

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