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Abdominal Pain in a 20-Year-Old Woman

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Abdominal Pain in a 20-Year-Old Woman INTERNAL MEDICINE BOARD REVIEW A SELF-TEST ON A CME EDUCATIONAL OBJECTIVE: Readers will consider less common causes of abdominal pain CREDIT and nonspecific diarrhea CLINICAL LAKSHMI S. PASUMARTHY, MD DUANE E. AHLBRANDT, MD JAMES W. SROUR, MD CASE Clinical Faculty, Internal Medicine, York Clinical Faculty, Gastroenterology, York Clinical Faculty, Gastroenterology, York Hospital, Hospital, York, PA Hospital, York, PA York, PA Abdominal pain in a 20-year-old woman 20-year-old woman presents to the Her laboratory values A emergency department with postpran- • White blood cell count 10.2 × 109/L (nor- dial epigastric and right-upper-quadrant pain, mal range 4–11) sometimes associated with nausea. She has • Red blood cell count 4.71 × 1012/L (3.9–5.5) been having six to eight loose bowel move- • Hemoglobin 14.4 g/dL (12–16) ments every day, with no blood or mucus, and • Hematocrit 42.4% (37%–47%) she has lost about 20 lb despite a good appetite. • Mean corpuscular volume 90 fL (83–99) The diarrhea did not improve when she tried • Mean corpuscular hemoglobin 30.6 pg omitting milk products and carbohydrates. (27–33) Her symptoms began several months ago, • Platelet count 230 × 109/L (150–400) but she says that 3 days ago the pain worsened • Red cell distribution width 13.3% (11.5%– steadily, radiating to the middle of her back, 14.5%) with associated episodes of nonbloody, nonbil- • Sodium 140 mmol/L (132–148) ious emesis. She cannot keep down liquids or • Potassium 3.3 mmol/L (3.5–5.0) solids. She says she has never had such epi- • Chloride 104 mmol/L (98–111) Her height sodes in the past. • Bicarbonate 28 mmol/L (23–32) is 66 inches, She reports no oral ulcers, urinary symp- • Blood urea nitrogen 9 mg/dL (8–25) toms, skin rashes, musculoskeletal pain, or • Creatinine 0.8 mg/dL (0.7–1.4) weight 116 lb, neurologic symptoms, and she denies being • Glucose 87 mg/dL (65–100) BMI 18.7; anxious or depressed. • Alanine aminotransferase 26 U/L (0–45) she has lost She has no history of serious illness, surgery, • Aspartate aminotransferase 21 U/L (7–40) or hospitalization. She smokes a half pack of • Alkaline phosphatase 101 U/L (40–150) 20 lb despite a cigarettes a day, drinks alcohol occasionally, • Total bilirubin 0.8 mg/dL (0–1.5) good appetite and smokes marijuana occasionally. She is em- • Albumin 3.5 g/dL (3.5–5) ployed as a certified nursing assistant. • Pregnancy screen negative She is taking ethinyl estradiol-levonor- • Urine toxicology screen negative. gestrel pills for birth control and takes calcium carbonate as needed for abdominal discom- Physical examination fort. She is taking no other medications, in- The patient is very thin and appears quite cluding nonsteroidal anti-inflammatory drugs uncomfortable. Her temperature is 99.7°F (NSAIDs). (37.6°C), pulse rate 101, respiratory rate 18, Her maternal uncle died of colon cancer at blood pressure 111/67 mm Hg, and oxygen age 32, and her mother had colon polyps on saturation 96% on room air. Her skin is warm colonoscopy. There is no family history of in- and dry. Her height is 66 inches, weight 116 flammatory bowel disease or celiac sprue. Her lb, and body mass index 18.7. father committed suicide. Examination of the head and neck shows normal dentition, dry mucus membranes, and no oral exudates. The thyroid is normal, and doi:10.3949/ccjm.77a.09067 no masses or lymphadenopathy are noted. CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 1 JANUARY 2010 45 Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. ABDOMINAL PAIN Heart sounds and rhythm are normal, and gastroduodenal involvement have previously the lungs are clear with no crackles or rubs. been diagnosed with ileocolic disease, and The abdomen is scaphoid and soft, with no gastroduodenal involvement manifests later. distention. She has epigastric tenderness but Nonradiating epigastric pain is very common. no rebound, guarding, rigidity, palpable mass, Obstructive symptoms due to gastroduodenal or costovertebral angle tenderness. Bowel strictures (eg, postprandial vomiting, epigas- sounds are normal. The neurologic examina- tric pain, weight loss, bloating) are also com- tion is normal. mon.2 Duodenal ulcer. The most important fac- ■ NARROWING THE DIAGNOSIS tors responsible for duodenal ulcers are NSAID use and Helicobacter pylori infection.3 Duode- Given the history and findings so far, which nal ulcers have a variety of clinical presenta- 1is the least likely cause of her symptoms? tions, ranging from no symptoms to severe □ Lactose intolerance pain. Epigastric pain can be sharp, dull, burn- □ Celiac disease ing, or penetrating. Many patients complain □ Crohn disease of a feeling of hunger and weight gain—as op- □ Duodenal ulcer posed to gastric ulcer, in which patients expe- □ Eating disorder rience anorexia and weight loss. Abdominal pain generally occurs several hours after meals This young woman’s presentation has some and often awakens the patient at night. Pain is features found in all of these conditions. How- often relieved by food, but this phenomenon ever, the least likely is lactose intolerance. is present in only 20% to 60% of patients and Lactose intolerance results from a shortage probably is not specific for duodenal ulcer. of the enzyme lactase, which is normally pro- Our patient does not use NSAIDs, but some duced by the cells that line the small intestine. of her symptoms, such as postprandial pain, epi- Close to 50 million American adults have lac- gastric pain radiating to the back, and nausea tose intolerance. Common symptoms include and vomiting are seen with duodenal ulcer. She has no nausea, cramps, bloating, gas, and diarrhea, Eating disorders. The two main types of history of which begin about 30 minutes to 2 hours after eating disorders—anorexia nervosa and bu- eating or drinking foods containing lactose. limia nervosa—have a significant diagnostic NSAID use, Since the patient’s symptoms did not im- overlap,4 and a third type, binge-eating disor- and no signs prove when she tried omitting milk products, der, is currently being investigated and defined. of ulcer and since lactose intolerance is rarely associ- Girls and women are 10 times as likely as boys ated with pain radiating to the back and with and men to develop an eating disorder. on endoscopy severe vomiting, this is the least likely cause of People with anorexia have a distorted view her symptoms. of their bodies. Even when they are extremely Celiac disease presents with a myriad of thin, they see themselves as too fat. symptoms—sometimes without gastrointestinal Bulimia is characterized by binge-eating, (GI) symptoms. Anemia is the most common purging, and overexercising to compensate for laboratory finding, due most often to iron defi- the excess calories. Patients are often close to ciency, but also due to deficiencies of vitamin normal weight. 1 B12 and folate as a result of malabsorption. Binge-eating disorder involves the con- Our patient’s laboratory values—especially sumption of very large amounts of food in a her red cell indices—do not confirm this find- short period of time. About 2% of all young ing. One must also remember, however, that adults in the United States struggle with binge- hemoglobin tends to be falsely elevated in pa- eating. They are either overweight or obese. tients who are dehydrated. These disorders tend to be associated with Crohn disease often presents with occult other psychiatric disorders such as depression blood loss, low-grade fever, weight loss, and or obsessive-compulsive disorder. Our pa- anemia. Though the condition is most often tient sought medical attention and was ap- ileocolic, it can affect any part of the gastroin- propriately concerned about her weight loss, testinal tract. Nevertheless, most patients with which make an eating disorder unlikely. 46 CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 1 JANUARY 2010 Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. PASUMARTHY AND COLLEAGUES A B C On endoscopy, the second and third portions of the duodenum were FIGURE 1. A, sagittal CT with contrast shows the duodenum (arrow) compressed under narrowed, with the superior mesenteric artery (SMA). B, CT shows the narrow angle formed by the SMA (red arrow) and the aorta (white arrow). C, axial CT shows the duodenum (1) compressed prominent between the SMA (3) and the aorta (4). Also seen are the superior mesenteric vein (2), de- pulsations creased fat around the SMA, and the decreased distance between the SMA and the aorta. ■ CASE CONTINUED: Which of the following is the most likely SHE UNDERGOES CT 2diagnosis at this point? □ SMA syndrome We send our patient for computed tomography □ Chronic mesenteric ischemia involving (CT) of the abdomen with contrast (FIGURE 1). the SMA The stomach and duodenum are distended, □ Megaduodenum due to a connective and the duodenum is compressed under the tissue disorder superior mesenteric artery (SMA). Upper GI endoscopy shows a normal esophagus, normal SMA syndrome is the most likely diagno- gastric antrum, and normal duodenal bulb. sis. Despite its name, this syndrome is not a The second and third portions of the duode- vascular condition. It is an uncommon cause num are narrowed with prominent pulsations. of proximal intestinal obstruction in which CLEVELAND CLINIC JOURNAL OF MEDICINE VOLUME 77 • NUMBER 1 JANUARY 2010 47 Downloaded from www.ccjm.org on September 29, 2021. For personal use only. All other uses require permission. ABDOMINAL PAIN Aorta Superior mesenteric artery (SMA) SMA-aortic angle Duodenum FIGURE 2. Left, the normal angle between the superior mesenteric artery (SMA) and the aorta is 25 to 60 degrees.
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