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Abdominal and Pelvic Pain

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An 81-year-old diabetic woman with a history of atrial fibrillation is transferred to your emergency department (ED) from the local nursing home with a note from the facility stating that she was complaining of abdominal pain and vomited once. Her vital signs in the ED are blood pressure (BP) 105/75 mm Hg, heart rate (HR) 95 beats/minute, respiratory rate (RR) 18 breaths/minute, and temperature 100.1°F. The patient appears very uncomfortable and has not stopped moaning in pain since arriving to the ED. You are surprised to find that her abdomen is soft and nontender on palpation. Which of the following diagnostic tests is most likely to reveal the cause of her symptoms?

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a. Capsule endoscopy

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b. Colonoscopy

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c. CT angiography of the abdomen

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d. Ultrasound

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e. Abdominal radiograph

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The answer is c. This patient has mesenteric ischemia secondary to a thromboembolism from atrial fibrillation. The classic presentation of acute mesenteric ischemia is sudden onset of poorly localized abdominal pain in an individual with underlying cardiac disease. Arterial emboli are the most common cause of acute mesenteric ischemia, responsible for approximately 50% of cases. Most emboli are cardiac in origin, arising from mural thrombi or valvular lesions. Atrial fibrillation is an important risk factor for mesenteric ischemia owing to the propensity to form mural thrombi. Mesenteric ischemia can also occur as a result of thrombosis within mesenteric arteries, typically seen in patients with advanced atherosclerotic disease. Physical examination findings are notable for “pain out of proportion to examination” where a patient may be writhing from abdominal pain but have a soft, nontender abdomen. While mesenteric angiography remains the gold standard for diagnosis of acute mesenteric ischemia, CT angiography has largely supplanted traditional angiography and is the initial test of choice for mesenteric ischemia. Vascular surgery should be consulted emergently if mesenteric ischemia is suspected.

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Capsule endoscopy (a), colonoscopy (b), and ultrasound (d) are not part of the initial management of mesenteric ischemia. Abdominal radiographs (e) may be abnormal, but are not sufficiently specific to diagnose mesenteric ischemia.

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A 49-year-old man with a history of alcoholism presents to the ED with nausea, vomiting, and abdominal pain that began approximately 2 days ago. He usually drinks a six-pack of beer daily, but increased his drinking to two six packs daily over the last week because of increased stress at work. He notes decreased appetite over the last 3 days and states he has not had anything to eat in 2 days. His BP is 125/75 mm Hg, HR is 105 beats/minute, and RR is 20 breaths/minute. You note generalized abdominal ...

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