Abdominal Pain – Multiple Differentials NP Virtual Rounds February 10, 2009

History of Presenting Illness  44 y/o female with c/o 12 day hx of progressive abdominal pain  S: sudden onset of abd pain 12 d ago following a spicy meal; pain persistent and progressive, often worse after meals & at night, started LRQ now epigastric & URQ, no N, V, or anorexia, hemoptysis, no HA, no stiff neck, no ear pain/tinnitus, no vision changes, indigestion, BMs normal w/ LBM yesterday, no urinary symptoms, no problems w/ menses  Presented to clinic this am d/t intense, burning pain now at epigastric, kept her awake through the night, travels upper R to L w/ fever, ++ diaphoresis, alternating chills & hot flushes, no rigors, pt wonders if has food poisoning. Rates pain currently as intense

Past Medical History  Hysterectomy d/t fibroids & endometriosis, I ovary removed – no pregnancies, no risk of ectopic pregnancy  No other surgeries, hx of serious illness, trauma  Partial excision of intramural fibroid  No hx of IBS, GERD, no bowel disease – crohn’s, colitis, no hx of gallbladder disease, or diverticulitis

Other History  No medications  No allergies  N/S, no ETOH, no recreational drugs/OTC/herbals/home remedies  Nothing taken to deal with current illness  Social hx: lives alone on a boat, works at Hollycock; active and healthy, no recent travel out of the country

Physical Exam  Thin, pale, diaphoretic woman, looking less than stated age  Alert, oriented, able to give good history – no recent URI/cold  VS: T 38.1, BP 106/62, HRR 70, RR 20  Urine dip: small WBC, neg nitrates, pos protein, trace blood  HEENT: TM – slightly red, serous fluid? No lymphadenopathy, neg Kernig sign, neg Brudzinski sign  Resp: CTA, no CVA tenderness  CVS: S1 S2, no S3, S4, no murmurs/bruits  Abd: LKKS neg, discomfort over epigastric area w/ palpation, pos rebound tenderness & guarding RLQ otherwise normal, neg McBurney & psoas signs

Differential Diagnoses  ?Acute appendicitis  Gastroenteritis  Divertulitis  GERD  Biliary colic  Pyelonephritis

Plan  Need diagnostic work up  Labs: CBC, renal fx, LFTs, bilirubin, amylase, h. pylori  CT abd to r/o appendicitis (good standard)  Consult w/ ER  Transport via ferry accompanied by friend  Further assessment: elicit better info on pattern of pain i.e. colicky  Other tests? Yersinia enterocolitica Serology, US, Barium enema

Diagnosis & Management  Initial ER temp 38.7 slightly elevated WBC w/ L differential w/ neuts 8.2, mildly 130, U/A unremarkable w. significant RLQ guarding & rebound tenderness, pain colicky, RUQ Sx w/ no abdominal findings  CT scan = Mesenteric lymphadenitis w/ + mesenteric lymph nodes, normal appendix  Incidential finding 2 cm cyst R ovary & 1.3 hyperattenuating lesion post aspect R lobe of liver  Admitted for observation & rehydration

Follow Up  F/u post discharge – resolution of all her symptoms  U/S of liver to ensure lesion stability  What is mesenteric lymphadenitis:  Mesenteric lymphadenitis is an inflammation of the lymph nodes on the wall of the mesentery  Mesenteric lymphadenitis usually follow viral infection with the common cold, or with infection by Yersinia enterocolitica, Pseudo tuberculosis, Streptococcus viridansor Campylobacter jejuni

Mesenteric Lymphadenitis  CAUSE:  The bugs gain access to the wall of the intestine, and invade the lymph nodes on the covering of the intestines called the mesentery.  The small intestine is frequently more involved, but the large intestines or colon may also be involved.  The lymph nodes become enlarged due to inflammatory process induced by the micro-organisms.  The inflammatory process, coupled with the stretch effect on the wall of the mesentery by the enlarged lymph node cause pain.  Pus may form in severe cases and spread to cause disseminated infection.  Most times though, the infection resolves on it own without the need to do anything.

Mesenteric Lymphadenitis  The signs and symptoms of mesenteric lymphadenitis are very similar to those caused by appendicitis. They can however be differentiated from those of appendicitis by some subtle differences.  Abdominal Pain. This is often located in the right lower abdomen or right iliac fossa. It is a colicky abdominal pain which just resolves momentarily without any intervention.  Preceding Cold or Sore Throat. One thing in the history that gives away the diagnosis of mesenteric lymphadenitis is that of the presence of common cold or sore throat in the days or week before the onset of abdominal pain.  Fever. There may be an associated fever, running up to 38.5 degrees centigrade. Vomiting. Patient may vomit. If they vomited before the onset of pain, appendicitis is most unlikely. Diarrhoea. There may be episodes of loose stools, especially where Yersinia infection is involved. Appendicitis could also cause diarrhoea.  Anorexia. Usually, with mesenteric lymphadenitis, patients are still able to eat and drink. If a patient complains of abdominal pain, and appetite remains good, it is most unlikely he or she has appendicitis.