Belly Pain Bonanza

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This is our 3rd case in a case series exploring the care of patients with GI related illnesses in the Emergency Department.  Similar to our "Out on a Limb" and "Sepsis Smackdown" case series, the case presented is followed by a series of questions, with a discussion in the comment section facilitated by the post authors.  In approximately 1 month, the authors of the post will conduct a combined simulation/small group session reinforcing the learning points from the posts during Grand Rounds.  Around this time, they will also curate the comments from the discussion and publish a post highlighting these learning points.  Looking forward to a great discussion!

It's been a busy Monday night shift.  2 hours in and it seems like all you've seen is belly pain after belly pain.  You hesitate and think maybe it's just a figment of your imagination but a quick look at the track board tells you nope, 5 patient's with abdominal pain in your 10 bed pod and a new patient arriving to C40 with, of course, abdominal pain.  You meet the squad and get report.

James is a 42 year old gentleman who says that he has been vomiting for the past day. He looks uncomfortable, complains of non focal pain throughout his abdomen, and vomits non-bloody non-bilious emesis once after presentation. His vital signs are all within normal limits and you order up some labs and give him fluids and anti-emetics. He has had no dietary changes, no sick contacts, and no history of abdominal surgeries.  On exam he has a soft abdomen with predominately epigastric abdominal tenderness to palpation with voluntary guarding but no rebound tenderness.

His vitals and labs are notable for the following:

HR 108, BP 137/82, RR 14 O2 99% on RA.Temp: 99.8

  • CBC: WBC 15.4, hemoglobin 14.5, platelets 240
  • BMP: Na 132, K 4.8, BUN 22, Cr. 1.2
  • Hepatic: T Bili 1.2, ALT 87, AST 67, Alk Phos 105, Albumin 3.7
  • Lipase: 1230

When responding you need only respond to 1 or 2 questions (leave some fodder for others!) and please begin your response with Q1, Q2, etc, denoting to which question you are responding.

 

Question 1

What are the likely etiologies of these symptoms, and what are the initial steps of diagnosis?

Question 2

Changing the situation, let's say this is his second presentation for these same symptoms, and his lipase is elevated > 3 times normal but similar to what it was on his initial presentation, what factors of history, timing, or otherwise would spur you to obtain repeat cross-sectional imaging?

Question 3

It is 3 years later and this patient has become well known to your emergency department staff for coming in after drinking too much over the weekend and presents spitting up into a emesis basin and retching. You happen to be working again on a Monday evening and he shows up again, stating that he cannot keep anything down. You indulge him by giving him some fluids and obtaining labs, which show signs of mild dehydration but nothing else remarkable. What can you do to reduce recidivism for this patient other than recommend alcohol abstinence.

Question 4

Do scoring systems such as Ranson, Glasgow Blatchford, or Rockall help you in your daily practice?