A b d o m i n a l P a i n in
S p e c i a l Po p u l a t i o n s
Esther H. Chen,
*, Angela M. Mills,
Abdominal pain Immunocompromised Immunosuppressed
THE IMMUNOCOMPROMISED PATIENT
Patients with altered immunologic function comprise a heterogeneous population
ranging from those who are mildly immunocompromised (eg, elderly, uremic, diabetic)
to those who are moderately to severely immunocompromised (eg, current immunosuppressive therapy, post transplant, acquired immunodeficiency syndrome [AIDS],
active malignancy undergoing chemotherapy). Compared with immunocompetent
hosts, this population suffers from the same spectrum of diseases, but because of
their blunted immune response they may present with atypical symptoms such as
altered mental status and tachycardia, lack the classic signs of an acute abdomen,
and/or seek medical attention later in their disease course.1 For example, transplanted
organs lack native innervation, so even pain is an unreliable sign of underlying
disease.2 In addition to the surgical conditions that must be considered in any patient
with acute abdominal pain, the differential diagnosis should be expanded to include
nonsurgical problems and infections that may be unique to this population. These
diseases include cytomegalovirus (CMV) infection, neutropenic enterocolitis (typhlitis),
and intra-abdominal abscesses. Because they are so challenging to diagnose and are
more likely to harbor a potentially life-threatening disease, immunosuppressed
patients will often receive diagnostic imaging with abdominal-pelvic computed
tomography (CT) as part of their emergency department (ED) evaluation.
Human Immunodeficiency Virus/AIDS
The introduction of highly active antiretroviral therapy (HAART) has decreased the incidence of opportunistic infections (OIs) and gastrointestinal diseases. A retrospective
study of 108 human immunodeficiency virus (HIV)-positive patients (84% on
The authors have no financial conflict.
Department of Emergency Medicine, University of San Francisco, San Francisco General
Hospital, 1001 Potrero Avenue, #1E25, San Francisco, CA 94110, USA
Department of Emergency Medicine, University of Pennsylvania School of Medicine, 3400
Spruce Street, Ground Ravdin, Philadelphia, PA 19104, USA
* Corresponding author.
E-mail address: email@example.com
Emerg Med Clin N Am 29 (2011) 449–458
0733-8627/11/$ – see front matter Ó 2011 Elsevier Inc. All rights reserved.
antiretroviral therapy or HAART, 44% with CD4 200 cells/mm3) with undifferentiated
abdominal pain3 showed that only 10% of patients had an OI as compared with preHAART reports of 41% to 86%.4–6 Disseminated mycobacterial disease was the most
common diagnosis. Other OIs included Candida esophagitis, AIDS cholangiopathy,
lymphoma, and intra-abdominal tuberculosis. Well-described causes of abdominal
pain such as CMV colitis or peritonitis, cryptosporidiosis, and Kaposi sarcoma were
not seen at all in this San Francisco population. Moreover, only 9 patients (8%)
required surgical intervention, one of which was for drainage of a Mycobacterium
abscess (the only HIV-associated OI). A more recent study of opportunistic gastrointestinal disorders in HIV patients corroborated these findings, showing that 26% of
patients on HAART (vs 80% in the no-treatment group) had an OI, most commonly
Candida esophagitis and CMV esophagitis or colitis.7 Kaposi sarcoma and lymphoma
were less common.
The primary conditions requiring acute surgical intervention in HIV patients are
appendicitis, cholecystitis, bowel obstruction, and intestinal perforation.8 These
surgical conditions occur as frequently in HIV patients on HAART as in non-HIV
patients,7,9 although the underlying pathology may be different. In immunocompromised patients, CMV infection can cause vasculitis in the gastrointestinal tract leading
to ulcerations in the bowel wall, particularly in the terminal ileum and colon. CMV colitis
may present acutely as gastrointestinal hemorrhage, perforation, or toxic megacolon.10
Appendicitis can also be caused by CMV infection and may present with more indolent
symptoms. In addition, intestinal obstruction and intussusception may be caused by
Kaposi sarcoma and lymphoma.8,9 Finally, although gallstone cholecystitis occurs
equally in non-HIV and HIV patients, acalculous cholecystitis occurs more frequently
in the HIV population. Moreover, these patients can develop cholangiopathy, both as
an adverse effect of antiretroviral medications and from infiltration of opportunistic
pathogens into the biliary ducts causing obstruction.9
In addition to the conditions already mentioned, abdominal pain in HIV patients may
be an adverse effect of the same antiretroviral medications that have been shown to
decrease gastrointestinal diseases. Patients will often present with associated symptoms of nausea, vomiting, and diarrhea, sometimes severe enough to cause dehydration or hemodynamic instability. Some medications are associated with specific
conditions. For example, didanosine (Videx) can cause acute pancreatitis and indinavir (Crixivan) can precipitate in the kidneys, leading to nephrolithiasis.8 More often than
not, the discomfort caused by these medications results in intermittent medication
noncompliance and sometimes discontinuation of the treatment entirely.11 Lapses
in treatment may increase a patient’s risk of developing OI.
Approximately 40% of the ED visits by cancer patients are for abdominal pain.12 The
differential diagnosis of abdominal pain in this patient group should include conditions
directly related to the malignancy itself in addition to complications of the malignancy
treatment.13 Not surprisingly, intra-abdominal cancers increase a patient’s risk of developing a small bowel or large bowel obstruction,14 although non–intra-abdominal cancers
(ie, breast, melanoma) can also cause bowel obstruction due to diffuse peritoneal
carcinomatosis.15 A diagnosis of large bowel or gastric outlet obstruction in an otherwise
healthy patient or someone with a history of prior cancer should increase the suspicion of
an underlying or recurrent malignancy.13,14 Furthermore, solid tumors can become
a lead point in causing intussusception, which is otherwise uncommon in healthy
adults.16 Bowel perforation may be caused by transmural erosion of gastrointestinal
cancers, intestinal metastatic lesions, and atypical infections. Pneumoperitoneum can
Abdominal Pain in Special Populations
be challenging to diagnose, as patients may have difficulty localizing the infection and
therefore have a delayed presentation.1 In addition, patients with cancer can develop
malignant ascites, causing abdominal distention and pain, and Budd-Chiari syndrome,
a constellation of symptoms caused by hepatic venous outflow obstruction from
thrombosis.13 In evaluating these patients, Abdominal CT is more clinically useful
because it can detect closed-loop or strangulation obstruction, identify a transition point,
and diagnose intestinal pneumatosis or vascular thrombosis,13 as compared with plain
radiography, which has a sensitivity of only 66%17 for detecting small bowel obstruction
and an inability to identify strangulated bowel or vascular thrombosis.18
Gastrointestinal symptoms can also be an adverse effect of the treatment of the
underlying malignancy. Chemotherapeutic agents frequently cause abdominal pain
associated with nausea, vomiting, and/or diarrhea. Radiation therapy to the abdomen
or pelvis can lead to a progressive occlusive vasculitis and local narrowing of the intestinal lumen. Radiation enteritis is a spectrum of disease including acute bowel ulceration, intestinal perforation, and/or massive gastrointestinal hemorrhage, and may
lead to chronic fistula formation and strictures.19
Cancer treatment with chemotherapy can also cause profound neutropenia. In neutropenic patients, the most common cause of an acute abdomen is neutropenic
enterocolitis (NEC) or typhlitis.13 NEC is a necrotizing inflammation of the cecum
and the adjacent small intestine in the setting of chemotherapy-induced neutropenia
or bone marrow transplantation. Also known as necrotizing enterocolitis, it has been
described in patients with aplastic anemia, AIDS, and organ transplantation. Cytotoxic
agents such as the taxanes and vinorelbine (Navelbine) may also increase a patient’s
risk of NEC.20
Symptoms of NEC include fever, nausea, vomiting, abdominal distension, diarrhea,
and right lower quadrant pain, which may be initially thought to be due to appendicitis.
Patients may also present with hypotension and other signs of sepsis. Although the
symptoms of NEC may be difficult to distinguish from the routine side effects of the
chemotherapeutic agents themselves, it is more likely to be associated with bowel
wall thickening on abdominal CT of more than 4 mm, with a very poor prognosis if
greater than 10 mm (Fig. 1).21,22 Treatment includes fluid resuscitation, broadspectrum antibiotics effective for enteric gram-negative bacilli, Enterococcus spp,
and anaerobes, bowel rest, and parenteral nutrition as needed.20 Surgical intervention
is reserved for bowel ischemia and perforation.23 Mortality and morbidity rates are
high so prompt recognition may be life-saving.24
Fig. 1. Computed tomogram showing bowel wall thickening of neutropenic enterocolitis.
Solid Organ Transplant Patients
Like many postsurgical patients, the two most common reasons for solid organ transplant patients to visit the ED are abdominal pain (31%), often associated with other
gastrointestinal symptoms, and infectious symptoms (17%) such as fever or wound
infection.2 In this ED study, infection (36%) and gastrointestinal or genitourinary
pathology (20%) were the most common ED diagnoses, regardless of the time
elapsed since transplantation. Moreover, the majority of transplant patients (61%)
were hospitalized (compared with the 17% overall admission rate in the same institution during the study period), regardless of their diagnosis, presumably because
a missed diagnosis may have serious consequences for both the graft and the patient.
Any posttransplant patient with abdominal pain must be evaluated for organ rejection,
systemic infection, and drug toxicity.
Specific conditions to consider in these patients will depend on the time elapsed
since transplantation. In the early posttransplant period (1 month), postsurgical
complications and infections predominate.2 The surgical anastomosis may constrict
or leak, causing bowel obstruction or peritonitis. Graft injuries, such as bile duct
ischemia, can later become a liver abscess. Viral or candidal infections may be either
donor-derived or a surgical complication. Clostridium difficile colitis is also common
during this period, as opposed to OIs, which are typically absent.25 In addition,
patients have a slightly higher risk of graft rejection within the first month than within
the intermediate or late posttransplant period.2
During the intermediate posttransplant period (1–6 months), viral infections and
graft rejection are the most common reasons for patients to develop a fever.25
Because the full effect of immunosuppressants is now present, OIs such as CMV
colitis and intra-abdominal abscesses caused by fungal (eg, Candida, Cryptococcus)
and bacterial infections (eg, Nocardia, Legionella) may develop. These patients should
be considered severely immunocompromised and highly susceptible to infection.
In the late posttransplant period (6 months), the risk of infection typically declines
slightly as immunosuppressive therapy is tapered down in patients with good graft
function. However, patients continue to be at risk for developing chronic rejection,
often as a result of chronic viral infections.25 Acute diverticulitis is a common gastrointestinal infection seen during this period; patients may present with perforation due
to a delay in diagnosis. In addition, this population may also develop posttransplantation lymphoproliferative disorder (PTLD), a lymphoproliferative disorder thought to be
associated with Epstein-Barr virus infection. Patients with suspected PTLD may
present with fever, a mononucleosis-like syndrome, gastrointestinal obstruction,
bleeding, or perforation, and have significant hepatic or pancreatic dysfunction.
Regression of PTLD may occur with a reduction in immunosuppressant therapy,
although this disease often will require chemotherapy or immunotherapy.25
THE POSTPROCEDURE PATIENT
Percutaneous interventions are minimally invasive procedures increasingly being performed by interventional radiologists and noninterventionalists. Acute abdominal pain
and other gastrointestinal symptoms are common reasons these patients seek emergency care following their procedure. The remaining sections of this article focus on
the gastrointestinal complications of several common procedures.
Vena Cava Filters
Potential complications of inferior vena cava (IVC) filters include recurrent deep vein
thrombosis (DVT), IVC thrombosis, migration, fracture, and infection. Thus, acute
Abdominal Pain in Special Populations
abdominal pain or flank pain in a patient with an IVC filter may be due to a devicerelated complication. Older permanent filters are more likely to migrate or fracture
than those placed in the past 6 years (5%–30% [migration] and 2% [strut fracture]
vs 0.3%–3% and 0%, respectively) (Fig. 2).26–28 Filter or strut migration may be
entirely asymptomatic or may cause ischemic (vessel obstruction) or hemorrhagic
(vessel perforation) end-organ damage. Furthermore, limited IVC penetration by the
filter has increased recently from 10% to 95% with the newer filters,26,28 due to an
anchoring improvement that may partially explain the decrease in migration rate;
through-and-through caval penetration is rare. Patients with filter migration or more
significant caval penetration may report tearing pain in their groin or flank followed
by fever or signs of organ dysfunction (eg, small bowel obstruction, duodenal perforation, rectal bleeding). These patients require CT imaging for diagnosis and immediate
interventional radiology consultation for filter removal.
Percutaneous Gastrostomy Tubes
The major gastrointestinal complications of percutaneously placed gastrostomy, gastrojejunostomy, and jejunostomy tubes include peritonitis (1.3%) from pericatheter
leakage of gastric contents into the peritoneum, gastric perforation or hemorrhage
(1.7%), deep stomal infection or abscess (0.8%), and inadvertent injury to adjacent
organs during placement.29,30 Patients may also present with minor complications
including superficial wound infection, peristomal leakage, and tube malfunction (eg,
dislodgment, blockage, balloon rupture). A case series of 400 gastrostomy procedures reported 4 cases of peritonitis in patients with significant comorbidities; one
patient developed a liver abscess after inadvertent liver puncture during the
procedure.31 Major complications occur early, within a few days after the procedure,
and patients may present with abdominal pain and fever or severe sepsis. These
patients often require CT imaging to detect intra-abdominal abscesses or gastric
perforation, followed by interventional radiology or surgical consultation for tube
removal and/or abscess drainage.
Fig. 2. (A) IVC filter strut fracture. The arrows point to the broken struts. (B) IVC filter strut
fracture and migration.
Transvenous Hepatic and Renal Biopsy
Transvenous biopsies are most commonly performed on the liver and kidneys.
Most transvenous liver biopsy complications require no intervention and are
detected before hospital discharge.32 However, discharged patients may return
with abdominal pain radiating to the right shoulder, indicating a delayed formation
of a perihepatic hematoma. Ultrasonography of the right upper quadrant may be
used to confirm the diagnosis (Fig. 3). Acute intervention is often not required
unless there is associated hemodynamic instability or a significant, lifethreatening drop in the hemoglobin level. Finally, although transient pyrexia may
be routinely observed up to 24 hours after the procedure,33 persistent pyrexia
with concurrent gastrointestinal symptoms suggests the presence of an intrahepatic or perihepatic abscess and requires further evaluation.
Similar to liver biopsies, complications following transjugular renal biopsy typically
do not require acute intervention. Almost ubiquitous after a renal biopsy is gross
hematuria from a perinephric hematoma or calyceal hemorrhage (66%); both conditions typically resolve spontaneously.34,35 Patients with significant hematuria or symptomatic anemia due to an arteriovenous or arteriocalyceal fistula36 may develop
abdominal pain and distention from clot retention, with subsequent urethral obstruction. In this clinical scenario, the bladder must be manually irrigated through a largebore (20 French or larger) Foley catheter. Continuous bladder irrigation is often
reserved for patients without clot formation, as the clots can obstruct the smaller
lumen of the catheter and cause bladder perforation. Alternatively, patients with symptomatic anemia in the absence of hematuria may have a retroperitoneal hematoma37
also causing abdominal or flank pain. Urgent consultation for vessel embolization
should be obtained for patients with intractable bleeding or retroperitoneal bleed.
Transjugular Intrahepatic Portosystemic Shunts
Transjugular intrahepatic portosystemic shunts (TIPS) are used to treat patients with
complications of liver failure by diverting blood from the abnormally high-pressure
portal system to the low-pressure caval system.38 Because inadvertent puncture of
the hepatic capsule (5%–30%), gallbladder (5%–10%), and right kidney (2%) can
occur during the procedure,39 patients may develop acute abdominal pain or flank
pain from a slowly expanding perihepatic hematoma, acute cholangitis, or perinephric
Fig. 3. (A) Ultrasonogram showing perihepatic hematoma (H) post transvenous liver biopsy;
(B) Computed tomogram of the same patient, demonstrating perihepatic hematoma
following transvenous liver biopsy.
Abdominal Pain in Special Populations
hematoma, respectively. Acute ED management of TIPS-related issues requires stabilizing the patient, initiating treatment of the active issues (eg, antibiotics for infection,
blood transfusion for gastrointestinal bleeding), and obtaining CT imaging to identify
intra-abdominal sources of infection or bleeding.
Uterine Artery Embolization
Women who undergo uterine artery embolization (UAE) will often present to the ED
with abdominal/pelvic pain and vaginal discharge or bleeding.40–42 These symptoms,
along with bloating, fever, dysuria, hot flushes, mood swings, and fibroid passage, are
collectively referred to as postembolization syndrome, thought to be caused by fibroid
infarction.41 The two most clinically significant reasons for hospital readmission are
severe, intractable abdominal pain and pelvic infection.41 Even though the pain may
be caused by postembolization syndrome, fibroid passage, or fibroid necrosis—all
relatively benign conditions—the differential diagnosis should also include pelvic
infections (eg, endometritis, myometritis, infected necrotic leiomyoma, pelvic
abscess). The most reliable diagnostic study to distinguish a uterine infection or
abscess from postembolization syndrome is magnetic resonance imaging with gadolinium (Fig. 4).43 If this is not readily available, CT is preferred to ultrasonography.
Percutaneous Biliary Drains
There are 3 types of percutaneous biliary drains: external (sits above the obstruction
and drains bile into an external drainage bag), internal (metallic or plastic stent drains
into the bowel), and internal-external (external catheter enters a duct above the
obstruction and crosses the obstruction into the duodenum) drainage catheters.44
Two common causes of acute abdominal pain are intraperitoneal bile leakage and
tube obstruction, which can result in ascending cholangitis and intrahepatic
abscesses, especially in patients with malignant biliary obstruction.45 CT imaging
may be useful in detecting these fluid collections. Before imaging, a simple maneuver
that may promptly relieve the obstruction (and the patient’s pain) is to uncap the
external portion of an external or internal/external catheter where the external catheter
Fig. 4. (A) Magnetic resonance imaging (MRI) of the uterus, showing gas and inflammation
within the endometrium characteristic of endometritis; (B) MRI of the uterus, showing
extrusion of a uterine fibroid.
EMERGENCY DEPARTMENT MANAGEMENT
The ED management of patients with altered immunologic function and who are postprocedure includes immediate resuscitation, a broadened differential diagnosis with
timely diagnosis, and urgent consultation as appropriate. As these patients are at
high risk of abdominal emergencies, radiologic imaging such as CT or ultrasonography is often necessary to confirm a diagnosis and guide therapy. Infections, both
intra-abdominal and otherwise, should be treated with the appropriate antibiotics.
Patients with acute symptoms and an unclear diagnosis warrant admission until
serious pathology may be reasonably excluded.
Evaluation of abdominal pain in special populations includes recognition of atypical
and delayed patient presentations. As classic presentations of abdominal emergencies can be altered, life-threatening conditions may be easily missed. Consideration of the underlying condition of the patient (ie, immunocompromised host,
postprocedural) will enable the emergency practitioner to appropriately evaluate
and manage these patients for those specific disease processes in the differential
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