The Last (pronto-pup) Supper
Part I
It’s that time of the year again. A time when many in the North Star state
awaken to the gleeful thought of greasy food, crop art, bad tattoos, and animal
barns.
Whether you love the Minnesota State Fair…or hate it…you can’t
deny its ability to draw some of our state’s most eclectic characters.
-------------------
You are working a midweek evening shift at your home base
emergency department. You feel the pains
of hunger set in as you have, once again, managed to put off eating during a busy
shift. You hear (drifting across your well developed EM auditory radar) the
moans of someone who was clearly raised in the gopher state.
“OH GEEZ….oh Son-ovha-gun… I shun’ta ate that laast pronto
pup.”
You glance at the chief complaint: Abdominal pain.
The triage note goes on to describe an 84 year old female
who was attending the state fair when she began to have abdominal pain. She has a history of “mild diabetes” and
hypertension.
The nurse tells you that her daughter offers that she still smokes
a few cigarettes a day (while watching re-runs of the “Joker’s Wild” on the
game show channel.) Her daughter also notes that she requires occasional home
oxygen when her “emphysema acts up.”
VS: T: 98.6 HR: 67
BP: 114/77 RR 22 Sat 96%
You enter the room to see a frail 84 year old woman wearing
an “uffda” tshirt and rocking back and forth in bed. Your initial impression is
that she appears quite uncomfortable.
She notes that her pain developed tonight after eating a pronto-pup at
the state fair. She tells you that she
has been, “going to the fair for over 50 years and the pronto-pup supper has become a
family tradition.”
She notes that she has never had a problem with fried food but
“this time it got the best of me.” She
denies nausea and reports that her last bowel movement was earlier today and described as normal.
She denies prior abdominal
surgery.
Over the past few weeks she has noticed some increasing pain
associated with meals. She notes that her
family doctor, “checked my gall bladder and didn’t find anything.” She goes on to say that, “He thinks I could
have an ulcer.”
She has no allergies.
Her meds are Spiriva, Albuterol prn, Aspirin, and lisinopril. She lives in the 1st floor of a
house. Her grandson lives on the second
floor. She smokes 3-4 cigarettes a day
and drinks “an occasional brandy manhattan.”
You examine the patient:
General: Moderate to severe distress due to abdominal pain.
HEENT: NO scleral icterus
Lungs: barrel chested, no crackles, no wheezes
Cardiovascular: RRR, 3/6 SEM at right sternal border.
Abdomen: Normal bowel sounds, no focal tenderness with
palpation, no distention.
Extremities: warm
Skin: dry, no rash
After you finish your exam she tells you that she is very
disappointed because she was hoping to see her granddaughter participate in the
Llama Costume Parade at 6pm followed by the Patty Labelle
concert with her daughter at 730pm. She is
afraid that, “the darn pronto-pup messed everything up.” Her daughter pulls out a newspaper article
about the llama parade (the best kept secret of the fair) and asks if you know
any Patty Labelle songs.
You try to convey reassurance with a completely blank stare,
give your best ‘Minnesota Nice’ smile, and finish with a subtle slow apologetic shake of the head.
You gracefully exit the room and dash to your computer for safety.
What is the first thing you want to order upon leaving the
room?
What is your differential diagnosis?
What tests do you want to order: labs/imaging?
------------------------------TO BE CONTINUED --------------------------------
Part II
1.
When you leave the room you should immediately think about ordering pain
meds. Your patient is un-comfortable;
the one thing you can do is treat her pain.
You order 0.5 mg of diluaded. You also order a 500ml bolus of normal
saline.
2.
Differential Diagnosis:
-small
bowel obstruction
-acute
cholecystitis
-choledocholithiasis
-perforated
ulcer
-perforated
viscus
-sigmoid
volvulus
-pancreatitis
-appendicitis
-diverticulitis
-mesenteric
ischemia
-acute
gastritis
-colitis
-aortic
aneurysm
-aortic
dissection
-irritable
bowel
-pyelonephritis
-nephrolithisis
-others?
3.
Tests
Labs:
WBC: 7.4
Hgb: 10.3
Plt: Normal
Electrolytes: normal
Creatinine: 2.2 (GFR <60 o:p="">
LFTs: Normal
Lipase: Normal
Lactate: 4.1
Imaging:
- CT without contrast (due to poor GFR you elected to start with a non-contrast CT): No cause identified.
You
recheck your patient. She has had no
relief from dilauded, in fact, she looks more uncomfortable. You re-examine her
abdomen and she has no focal tenderness with palpation but tells you “my belly
hurts all over.”
You
order a second dose of dilauded.
You
are concerned about her elevated lactate and specifically about mesenteric
ischemia. She has multiple risk factors
and based on your assessment her pain is out of proportion to exam.
You
consult general surgery. You request
that they evaluate your patient and communicate that you are specifically concerned
about mesenteric ischemia. They review
the CT and request that you get a CT with contrast. You agree to order additional testing and
kindly confirm that they will be coming to evaluate the patient in the ED. You kindly request an estimated time. They tell
you that they are “just finishing up a procedure and will be down within 30
minutes.”
The
nurse approaches you and reports that the patient just had a bowel movement
that included bright red blood.
You
reexamine your patient. She has gotten
two doses of dilauded . She is still in
pain.
You
order a third dose of narcotic analgesia.
CT
with contrast is obtained and shows: mesenteric edema with
irregular thickening of the wall of the small and large bowel. Diffuse
large-vessel disease involving superior mesenteric artery, superior mesenteric
vein, inferior mesenteric artery, and inferior mesenteric vein.
You
re-page general surgery and they tell you that they are on their way.
She
is ultimately transferred to the OR. A
large amount of ischemic appearing bowel is resected.
She is admitted to the ICU and ultimately
expires 7 days later.
Summary:
Mesenteric Ischemia
Acute
mesenteric ischemia (AMI) has a very high mortality rate which ranges somewhere
between 60% to 80%. It is caused by inadequate
blood flow through the mesenteric vessels, resulting in ischemia and eventual
gangrene of the bowel wall. Although relatively rare, it is a life-threatening
condition.
Broadly,
AMI may be classified as either arterial or venous. I think it is easiest to think of 4 causes.
-
Arterial Emboli (most common, sudden, often with
bloody diarrhea)
-
Mesenteric arterial thrombus (progressive ischemia with eventual
occlusion. Often history of pain after
eating.)
-
Non-occlusive Mesenteric Ischemia (hypo-perfusion of the gut usually
associated with other low perfusion states. Usually multiple comorbities.)
-
Mesenteric Venous Thrombosis (Least common. Often related to inherited or acquired
coagulopathy. )
The 4
types of AMI have somewhat different predisposing factors, clinical pictures,
and prognoses. However, because the 4 types of AMI share similarities and a
final common pathway (ie, bowel infarction and death, if not properly treated),
for the purposes of this conversation it is useful to discuss them together.
Our
patient likely had mesenteric arterial thrombus and possibly and arterial
embolic event.
Unfortunately
there is no great test to immediately rule out mesenteric ischemia.
THERE IS
NO SUBSTITUTE TEST FOR CLINICAL SUSPICION.
Lactate
is non-specific to mesenteric ischemia. Elevated lactate can increase your
suspicion but does not make the diagnosis.
CT is certainly helpful but can fail to diagnose mesenteric ischemia up
to 23% of the time.
In some
cases interventional radiology may have a significant role to play and you
could consider calling them in conjunction with the surgeon. If there is an isolated mesenteric thrombus,
it may be most appropriate to transfer the patient to interventional
radiology. Possible emergent treatments
include: Papaverine infusion, surgical embolectomy, and intra-arterial
thrombolysis.
You
will want to initiate broad-spectrum antibiotics in the ED and consider
anticoagulation (heparin) if no contraindications exist.
Below
is a link to the “best kept secret at the fair” article. (Thanks to Marilyn U for this great tip)
Also,
for extra points can you name my favorite Patti Labelle song/video? hint it was
included on the 1985 Beverly Hills Cop Soundtrack and peaked at Number 17 on
the pop chart. (You gotta watch this.)
And
finally, no discussion of the Minnesota State Fair would be complete without at
least one tattoo:
Questions:
1. The best method for diagnosing mesenteric ischemia is:
a. lactate
b. CT with contrast
c. CLINICAL SUSPICION
d. bedside ultrasound
2. True or False: Lactate is both sensitive and specific for mesenteric ischemia.
3. The most common form of mesenteric ischemia is:
a. arterial emboli
b. mesenteric arterial thrombus
c. non-occlusive mesenteric ischemia
d. mesenteric venous thrombus
4. Mortality rates for mesenteric ischemia range from
a. 10-20%
b. 20-30%
c. 30-50%
d. 60-80%
5. True of False: Treatment options for mesenteric ischemia include both surgical and interventional radiologic procedures.
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