A Noncompliant Construction Worker With a Pulsating Abdomen

Muthunivas Muthuraj; Rahul R. Borra; Panagiotis Iakovidis, MD

Disclosures

November 22, 2021

Discussion

Based on the patient's symptoms and physical examination findings, a thorough differential diagnosis was developed. The most probable conditions in the differential were acute pancreatitis, acute mesenteric ischemia (AMI), chronic mesenteric ischemia (CMI), and abdominal aortic aneurysm (AAA).

The patient's initial presentation raised suspicion of acute pancreatitis. His atherosclerosis, hypercholesterolemia, and prolonged history of smoking, combined with physical symptoms (such as abdominal pain), made acute pancreatitis seem probable. However, although his cholesterol and triglyceride levels were elevated, the values were not high enough to confirm a diagnosis of acute pancreatitis. Furthermore, the patient's mild elevation in pancreatic lipase level compared with the reference range was not significant enough to warrant further evaluation. Thus, acute pancreatitis was ruled out as a potential diagnosis.

As the patient provided more information about his pain, he mentioned a pulsatile sensation in the middle to lower abdominal region. He stated that the pulsation increased in severity with the consumption of solids or liquids, especially those with a high fat content.

During the physical examination, a soft bruit was palpated in the abdomen, indicating an impediment to blood flow. This finding raised suspicion of either AMI or CMI. Further examination of the abdomen revealed an increased circumference of the distal abdominal aorta. As a result, AAA was added to the differential diagnosis.

AMI is a condition in which there is a sudden disruption of blood flow to the small intestine. This disturbance is typically caused by a dislodged embolus or thrombus that originated elsewhere in a patient's vasculature, usually within the aorta. Of all episodes of AMI, 50% are due to dislodged emboli, 15%-25% to dislodged thrombi, and less than 15% to thrombosis of the mesenteric veins.[1] AMI is a rare condition that occurs in only about 0.09%-0.2% of patients.[1] A characteristic symptom of AMI is abdominal pain that is out of proportion compared with the physical examination findings. Additional symptoms include nausea, vomiting, and diarrhea.

If AMI is left untreated, perforation of the small bowel can occur as a result of necrosis. The best test for AMI is CT angiography of the abdominal region. Because of the presence of gas in the abdomen, it can be difficult to diagnose AMI with ultrasonography. Although the patient in this case had abdominal pain and showed signs of abnormal blood flow in his abdominal region, his pain was chronic and not severe. Thus, AMI was a less probable diagnosis.

CMI was also considered in this patient because of his abdominal pain as well as his history of atherosclerosis, hypercholesterolemia, and heavy smoking. The cause of CMI is atherosclerosis in the celiac, superior mesenteric, or inferior mesenteric vessels.[2] Eventually, the buildup of plaque occludes blood flow to portions of the small or large bowel. CMI is diagnosed in about 9.2 of every 100,000 persons with atherosclerosis.[3] Patients with CMI typically present with dull postprandial abdominal pain. Some patients may not even experience postprandial pain because of the formation of collateral vessels. Like AMI, CMI is confirmed with CT angiography.

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