Author: Peter Kvapil, MD Series Editor: Richard Goodgame, MD

Disclosures

July 06, 2004

Case Presentation

A 58-year-old man presented with 2 days of progressive, severe abdominal pain and feculent vomiting.

Two years ago the patient experienced a sharp, nonradiating, right upper quadrant pain associated with nausea that lasted for about 3 hours. Since then he has had similar episodes every few months. There were no precipitating or ameliorating factors. Four weeks prior to this current admission, the severity and frequency of the episodes increased. Several times per week, usually about an hour after a meal, the patient would experience epigastric bloating followed by severe right upper quadrant pain, nausea, and vomiting of undigested food. Two days prior to admission he developed for the first time abdominal distension, diffuse abdominal pain (worse around the umbilicus), nausea, and feculent emesis. He was not able to tolerate even liquids. There was no hematemesis, hematochezia, or melena. He has lost 10 pounds during the last 6 months. He has not had fever, chills, or night sweats.

His medical history is positive for hypertension treated with metoprolol, an ischemic stroke 2 years ago with no residual deficit, and moderate tobacco and alcohol use. He is not taking nonsteroidal anti-inflammatory drugs and has no significant family history of disease.

Physical examination showed a pulse rate of 105 beats/minute, blood pressure of 92/64, and temperature of 99.2°F. There was poor skin turgor and dry mucous membranes. The abdomen was distended and tympanic to percussion. There was generalized abdominal tenderness with some mild rebound tenderness. Bowel sounds were increased in frequency, volume, and pitch. A succussion splash was audible with abdominal agitation. Liver and spleen were not palpable. There was no stool in the rectum, but the rectal exam was otherwise normal.

Routine laboratory studies revealed the following:

Hemoglobin: 14.3 g/dL
White blood cell count: 11.4 x 103 cells/mm3
Polymorphonuclear leukocytes: 86%
Blood urea nitrogen: 35 mg/dL
Creatinine: 2.8 mg/dL
Total protein: 7.8 g/dL
Albumin: 3.5 g/dL
Total bilirubin: 1.2 mg/dL
Direct bilirubin: 0.3 mg/dL
Alkaline phosphatase: 127 U/L
Alanine aminotransferase: 79 U/L
Aspartate aminotransferase: 54 U/L
Amylase: 674 U/L
Lipase: 557 U/L
International normalized ratio: 1.1

The abdominal radiograph showed a dilated fluid-filled stomach and distended loops of proximal small bowel (not shown). No other useful diagnostic abnormalities were noted.

The patient was thought to have small bowel obstruction. He was treated with nasogastric suction, which produced abundant fluid with feculent odor. He was also given intravenous fluids and antibiotics. All of the abnormal laboratory values quickly normalized and the patient's condition improved.

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