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Our errors in diagnosing abdominal pain slides


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Our errors in diagnosing abdominal pain slides

  1. 1. Best Doctors Physician Webinars Case Studies in Diagnostic Errors: Our Errors in Diagnosing Abdominal Pain
  2. 2. Deepak Bhatt, MD, MPH Senior Physician, Cardiovascular Medicine, Brigham and Women's Hospital Professor, Harvard Medical School Norton Greenberger, MD Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital Clinical Professor of Medicine, Harvard Medical School Martin Samuels, MD, MSc, FAAN, MACP, FRCP Chairman, Department of Neurology, Brigham and Women’s Hospital Professor of Neurology, Harvard Medical School Moderator and Panel
  3. 3. Tonight 3 things you need to know • Best Doctors provides medical consultations/second opinions through a unique and collaborative analytical process • If you are an elected Best Doctor you are invited to consult on cases (and earn an honorarium) • Free pilot program – physicians may initiate collaborations on their complex cases
  4. 4. Abdominal Pain Dr. Martin Samuels
  5. 5. 37 Year Old Man with Abdominal Pain • 37 year old man complained of left lower quadrant abdominal pain for about six months • The pain radiated from the left flank, down along the inguinal ligament and into the left testicle • The pain was usually not there on awakening but worsened as the day progressed • Jogging greatly worsened the pain
  6. 6. 37 Year Old Man • The abdomen was non-tender • No masses could be palpated • Liver was normal size • Spleen non-palpable • No bruits heard • A well healed appendectomy incision (done at age 23) • Some numbness around the incision • Rectal exam normal; guaiac negative
  7. 7. 37 Year Old Man Workup • Renal ultrasound normal • Urinalysis repeatedly normal • Abdominal and pelvic CT normal
  8. 8. 37 Year Old Pain • Lidocaine injection at the edge of the incisional scar at the iliac crest relieved the pain temporarily but it returned unchanged • A consultation was obtained
  9. 9. 37 Year Old Man • Neuromuscular specialist diagnosed an iliohypogastric nerve entrapment • The incision was explored and the nerve released • The symptoms resolve, never to return • Nerve arises from T12 and L1 • Referred pain accounts for symptoms, which imitate renal colic
  10. 10. Iliohypogastric Nerve
  11. 11. Iliohypogastric Nerve Block From Medscape Needle entry for iliohypogastric nerve block Needle entry point for genital branch genisofomoral nerve Anterior superior Needle entry for XXX nerve block Public tubercle
  12. 12. Abdominal Pain Dr. Norton Greenberger
  13. 13. M.S. 37 y/o Female MGH 2010 • Unexplained illness, Fever, Chills, Nausea, Fatigue, Diarrhea since late 2009 • Unremarkable physician exam • Extensive Work up
  14. 14. Summary of Prior Laboratory, Endoscopy and Imaging Studies 2009-2011 Negative/Normal Laboratory: Cultures: urine, blood stool (-) HIV, Lyme, CMV, Viral Hepatitis markers TSH, FT4 Prolactin Serum Serum tryptase ACTH stimulation x 2 NL Urine Catecholamines Urine 5 HIAA CMP 20 ESR, CRP ANA + 1:320 C-1-esterase TTG – AB (-) SSA SSB Sjögren (-) Octreotide scan (-)
  15. 15. Imaging: • Head CT • Head MRI • Abdomen MRI • Chest CT • Cardiac stress echo normal Endoscopy: EGD (-) Hypotensive after EGD
  16. 16. Initial BWH Work Up History: • Flushing • Headaches • Sweats • Forget fullness • Occasional abdominal pain and distension • Inordinate fatigue • Alcohol intolerance • Red skin after hot shower • POTS syndrome on Rx 2-4 liter fluid 1-2gm/NaC1/day
  17. 17. Physical Examination: • T-98; P 78; BP 113/67; WT 170 • Skin: Marked dermatographism Mantle flush • Lungs: Clear • Cardiac: NSR, no murmers Abdomen: • Liver 11cm - ↓ 2-3 cm • Extremties No c,c,e • Neuro: Sluggish DTRs Impression: MCAS
  18. 18. M.S. Orthostatic Tachycardia 10/14/2010 Heart Rate Supine 75 Tilt Table 107 after 6’ Baseline 78 Standing 3’ 116 Exaggerated postural tachycardia Valsalva maneuver – Normal heart rate and blood pressure response
  19. 19. 24 hour urine N-methyl histamine 96 (<200) Prostaglandin F2 867 (<1000) Labs:
  20. 20. Rx: • Loratidine 10mg/b.i.d. • Ranitidine 150mg/b.i.d. • Singulair 10mg/q.d. • Cromolyn 200 mg/q.i.d.
  21. 21. Pt. MS follow up May 2012 • *flushing minimal • *headache occasional • *sweats minimal • *mental fog 2-3/10 point scale • *inordinate fatigue persists • *abdominal pain minimal • *diarrhea none • *menses,heat, exercise -accentuate Sx’s
  22. 22. Mast Cell Activation Syndrome History – Typical *Unexplained flushing-mantle distribution *Alcohol intolerance *Symptoms triggered by aspirin, NSAIDS, opiates *Exposure to hot and cold temperatures *Abdominal pain with/without diarrhea History – Additional Symptoms *Headaches *Irritability *Sweating *Difficulty expressing oneself *Lack of ability to concentrate *Mood changes Presentation on Physical Exam *Dermatographism, flushing *Labs: serum tryptase, urine *Sites of abdominal pain (RLQ, LLQ) histamine and prostaglandin D2/F2 Treatment *Responds to H1 & H2 blockers, cromolyn, and singulair
  23. 23. Abdominal Pain in a Post-Operative Vascular Surgery Patient Deepak L. Bhatt MD, MPH, FACC, FAHA, FSCAI, FESC Senior Physician, Brigham and Women’s Hospital Senior Investigator, TIMI Study Group Professor of Medicine, Harvard Medical School
  24. 24. Disclosure for Dr. Bhatt Advisory Board: Elsevier Practice Update Cardiology, Medscape Cardiology, Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of Chest Pain Centers; Chair: American Heart Association Get With The Guidelines Steering Committee; Honoraria: American College of Cardiology (Editor, Clinical Trials, Cardiosource), Belvoir Publications (Editor in Chief, Harvard Heart Letter), Duke Clinical Research Institute (Clinical Trial Steering Committees), Population Health Research Institute (Clinical Trial Steering Committee), Slack Publications (Chief Medical Editor, Cardiology Today’s Intervention), WebMD (CME Steering Committees); Other: Senior Associate Editor, Journal of Invasive Cardiology; Data Monitoring Committees: Duke Clinical Research Institute, Mayo Clinic, Population Health Research Institute; Research Grants: Amarin, AstraZeneca, Bristol-Myers Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company; Unfunded Research: FlowCo, PLx Pharma, Takeda. This presentation discusses off-label and/or investigational uses of various drugs and devices.
  25. 25. Case • 78 year old male with abdominal pain post-op day #2 after R-sided fem-pop for rest pain in right foot.
  26. 26. PMH • HTN x 30 years • Diabetes diagnosed 20 years ago • Former smoker; quit 10 years ago; >50 pack-years • COPD x 10 years • Peripheral artery disease – R foot pain at rest; found to have long occlusion of R SFA with poor collateralization. Referred for fem-pop bypass.
  27. 27. Medications • Aspirin 81 mg daily • Metformin 1000 mg BID • Ramipril 5 mg daily • Metoprolol XL 100 mg daily (recently increased from 50 mg) • HCTZ 25 mg daily • Simvastatin 20 mg daily • Inhalers – prescribed, but not taking • NKDA
  28. 28. Social History • Married. Two grown children. Retired engineer. Smoking history as above. Occasional ETOH.
  29. 29. Operative Course • General anesthesia • Episode of transient hypotension, otherwise unremarkable
  30. 30. HPI • POD #2, doing well from vascular surgery perspective • Extubated, on RA with O2 sat of 92% • BP 90/50, HR 50, RR 14, T 99.2 • Complains of nausea, 1 episode of emesis • ROS positive for abdominal pain • Exam notable for – Decreased breath sounds, but no wheezing – No murmurs – + BS. Mild RUQ tenderness on deep palpation – No edema. Moderate sized hematoma at R femoral arteriotomy site with moderate tenderness
  31. 31. Course • Blood cultures sent • Ultrasound of gallbladder ordered • Anti-emetics ordered with relief • Morphine ordered for pain from hematoma • Systolic blood pressure running 85-90 mmHg with HR 45-50 – Felt to be vagal from abdominal pain and from hematoma – 500 cc NS bolus x2 ordered
  32. 32. Course • U/S of gallbladder done, shows thickened gallbladder walls and slight distention of gallbladder • Systolic blood pressure post bolus low 80s • Abdominal discomfort persists
  33. 33. Course • ECG recommended – Sinus bradycardia at 48. No ST elevation noted. • Cardiac biomarkers sent • Biomarkers return – positive troponin • ECG repeated – 2-3 mm ST depression in inferior leads (prior ECG on review showed ~1 mm ST depression in inferior leads) – Cardiology consulted – Patient taken to cath lab – 95% stenosis of mid RCA prior to a large RV marginal branch successfully stented
  34. 34. Lessons • Ischemia can manifest as abdominal discomfort, classically inferior (RCA) ischemia. • Ischemia can cause hypotension and bradycardia. • RV ischemia can be profound and refractory to initial fluid resuscitation. • Be wary for post-operative ischemia, especially in patients at high CV risk (even if “cleared” for surgery).
  35. 35. Thank you for joining us! • Read more on clinical decision support and social media & medicine on our blog at • Subscribe to our diagnostic accuracy newsletter at