ABDOMINAL PAIN – EMERGENCY MEDICINE 10 CASE STUDIES Q&A LATEST UPDATE A+

1) A 70-year-old diabetic woman with a history of atrial fibrillation is complaining of
severe abdominal pain. She has vomited once. Her vital signs are temperature 100.1°F,
blood pressure 104/76 mm Hg, heart rate 98 beats per minute and respiratory rate 20
breaths per minute. Her abdomen is soft on palpation. The patient has not stopped
moaning in pain since arriving to the hospital. You suspect mesenteric infarction. You
order an abdominal radiographic series to exclude gas under the diaphragm. Which
finding on plain abdominal film is strongly suggestive of mesenteric infarction?
a. Sentinel loop of bowel
b. No gas in the rectum
c. Presence of an ileus
d. Pneumatosis intestinalis
e. Air-fluid levels - Ans: (d)
This patient most probably has mesenteric ischemia secondary to a thromboembolism
from her atrial fibrillation. The typical patient with mesenteric ischemia may initially
present with pain that is out of proportion to the examination findings (ie, although the
patient is in pain, the abdomen is neither rigid, nor significantly tender on physical
examination). Abdominal distention and peritoneal signs are late findings and signal the
presence of bowel infarction. Plain abdominal radiographs are usually obtained early on
in the workup of acute abdomen. Although rare, the finding of gas in either the bowel
wall (pneumatosis intestinalis) or in the portal venous system is strongly suggestive of
intestinal infarct. This is a surgical emergency.
The choices a, b, c, and e are possible findings on radiography for patients with bowel
infarction. These findings are less sensitive and specific for infarction compared to
pneumatosis intestinalis. Air-fluid levels are typical of intestinal obstruction.
2) An 80-year-old man, while eating dinner, felt food get stuck in his chest. He drank a
glass of water, but shortly thereafter he vomited the water. His BP is 155/70 mm Hg, HR
is 98 beats per minute, RR is 18 breaths per minute, and oxygen saturation is 99% on
room air. What is the most common area for an esophageal foreign body to lodge in an
adult?
a. Aortic arch
b. Cricopharyngeus muscle
c. Tracheal bifurcation
d. Lower esophageal sphincter
e. Pyloric sphincter - Ans: (d)