The Resolution of Abdominal Pain: an Ominous Sign of Mesenteric Ischemia
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School of Medicine, Medical Student Center, University of California San Francisco, San Francisco, CA, USA; 2Department of Surgery, University of California San Francisco, San Francisco, CA, USA; 3Vascular Surgery Section, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA; 4Department of Medicine, University of California San Francisco, San Francisco, CA, USA; 5Medical Service, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA.
J Gen Intern Med DOI: 10.1007/s11606-020-06313-z © Society of General Internal Medicine 2020
INTRODUCTION
Acute mesenteric ischemia requires rapid diagnosis and treatment to reduce its substantial morbidity and mortality. In a patient over 75 years of age, it is a more common cause of an acute abdomen than appendicitis or a ruptured abdominal aortic aneurysm.1 Despite efforts to improve early diagnosis, the mortality of patients with acute mesenteric ischemia remains between 60 and 80%.2,3
CASE PRESENTATION
A 70-year-old man presented to the Emergency Department after 6 weeks of progressive post-prandial abdominal pain. Over the last 3 weeks, he had nausea, vomiting, non-bloody diarrhea, food aversion, and a 6.8-kg weight loss. Over the last week, his symptoms had progressed to the point that he was unable to eat or drink water or take medications without severe abdominal pain; in addition, the frequency of vomiting and diarrhea had increased to 4–6 episodes every day. On presentation, his abdominal pain was an 8 out of 10 in severity. His medical history included hypertension, hyperlipidemia, myocardial infarction, coronary artery bypass grafts, and peripheral artery disease treated with right femoral thromboendarterectomy and patch angioplasty. Six weeks prior to admission, he was diagnosed with multiple myeloma for which he had been prescribed ixazomib, lenalidomide, and dexamethasone. He was also taking oxycodone and ibuprofen for his abdominal pain. He discontinued all medications (except for lenalidomide and dexamethasone) 2 weeks prior to presentation, suspecting they could be exacerbating his symptoms, but there was no improvement. The patient was afebrile with blood pressure 112/70 mmHg, heart rate 103 beats/min, respiratory rate 16 breaths/min, and oxygen saturation 97% on room air. He was cachectic and had Received April 14, 2020 Accepted October 12, 2020L
a soft, non-distended abdomen without tenderness or guarding. The white blood cell count (WBC) was 14,060 cells/μL with an absolute neutrophil count of 11,260 cells/ μL. Other laboratory tests included normal liver biochemical tests and lipase, creatinine 0.95 mg/dL, C-reactive protein 100 mg/L (0.2–7.5), carbon dioxide 20 mmol/L (24–32), lactate 3.6 mmol/L (0.5–2.2), and troponin 0.05 (0.00–0.03). An electrocardiogram showed normal sinus rhythm with left ventricular hypertrophy. His tachycardia and lactic acidosis resolved with fluid administration, and his pain decreased after 4 mg of intravenous morphine and intravenous ondansetron. A fecal PCR assay for 22 enteric pathogens was n
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