Thanks to Dr. Fleischman for this interesting case
62 year old woman with obesity, htn, hld, copd presents with sudden onset left upper quadrant pain, painful respiration. No f,n/v/d. Patient is noted to be in pain, tachycardic, normotensive, and eupoxic. Patient refuses to lie on side for exam 2/2 pain, lung sounds difficult to assess secondary to body habitus, +wheezes, abdomen is soft and diffusely tender, extremities are cold and mottled.
What intraabdominal catastrophe does she have? Hint, her FAST exam reveals frank intraabdominal fluid. Aortic ultrasound appears normal. Don’t feel bad, you probably aren’t going to get it.
Abdominal Apoplexy (also known as Idiopathic Spontaneous Hemorrhage ISIH)
Apoplexy means to bleed within an internal organ
Non traumatic intraabdominal hemorrhage may be secondary to aneurismal rupture, solid organ malignancy, or inflammatory erosive process (pancreatitis). Hemorrhage without preceeding abdominal trauma is very rare. About 3000 cases have been reported to date according to a case report and review by Cawyer. The most common cause of spontaneous intraabdominal bleeding is aneurismal rupture, typically located at 2nd and 3rd branch point from aorta. 60% of aneurismal ruptures were found to involve branch of splenic artery (most commonly short gastric artery), 22% renal, 10% hepatic. Up to 30% can have no identifiable source. Bleed can be intraperitoneal or retroperitoneal.
They found that the patient normally has a typical course, before rupture patient has vague abdominal pain, there is a several hour latent period after rupture then patient rapid progresses to severe pain, peritonitis, hypotension, and then shock.
Diagnostic test of choice- FAST if unstable, CTA if stable.
Management- IR for embolization if area of bleed is known, otherwise Ex-lap for surgical exploration. Likely will need transfusion until bleeding corrected.
This patient was treated conservatively 2/2 to being a non op candidate and no active bleeding on CTA, was able to be discharged home.
Your Board Questions of the day:
1. Acute mesenteric ischemia is most commonly caused by:
a. Arterial thrombosis.
b. Arterial embolus.
c. Venous occlusion.
d. Hypercoagulable state.
e. Nonocclusive vascular disease.
The answer is b. Although all of the above can cause acute mesenteric ischemia, the most common cause is an arterial embolus.
2. A 23-year-old woman who has had an appendectomy is complaining of pain of the right lower quadrant, fever, anorexia, and dysuria. She vomited once, but denies diarrhea or constipation. Her last menstrual period was 12 days ago, and she takes oral contraceptives. Her temperature is 38.2 ◦ C (100.1 ◦ F). The examination shows tenderness of the right lower quadrant with local peritoneal signs, slight cervical motion tenderness, and right adnexal tenderness without mass. Laboratory test results show WBC, 12,500/mm 3 with 18% immature forms. Urinalysis shows 5– 10 WBCs and 10 RBCs per high-power field. Her pregnancy test is negative. The most likely diagnosis is:
a. Regional enteritis.
d. Acute salpingitis (PID).
e. Regenerative appendicitis.
The answer is a. Regional enteritis, like appendicitis, can cause inflammation of the ureter and result in pyuria and hematuria. The inflammatory process may lie next to the uterus and bladder, causing symptoms of dysuria and pelvic tenderness. Pyelonephritis may mimic appendicitis, although its presence is less likely without flank pain. Acute salpingitis may present with the same symptoms but is more likely to occur within 7 days of the last menses, and nausea, vomiting, and anorexia are less likely to occur. One or more episodes of acute salpingo-oophoritis usually precedes tubo-ovarian abscess. Pylephlebitis is septic thrombosis of the portal vein and the least likely diagnosis in this patient.
Lex, Joseph; Plantz, Scott H.; Kreplick, Lance W.. Emergency Medicine Q and A (3rd Edition).
New York, NY, USA: McGraw-Hill Professional Publishing, 2009. p 49.
Copyright © 2009. McGraw-Hill Professional Publishing. All rights reserved.
Cawyer JC, Stone K. Abdominal Apoplexy: A Case Report and Review. Journal of Emergency Medicine, 2011, Vol 40, No. 3. E49-52.