A 76-year-old woman with severe ischaemic heart disease being treated with aspirin, clopidogrel and metoprolol presents with severe abdominal and back pain, 6 hours after  being discharged home from a routine cardiac angiogram via the femoral route.

a)        How would you investigate the cause?

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College Answer

a)        How would you investigate the cause?

The differential could be large and could include pancreatitis, retroperitoneal haematoma, aortic dissection, cholecystitis, infarcted gut, G-I perforation, diverticular disease, pericarditis, myocardial infarction/ischaemia, pneumothorax. Investigation includes, a proper history (character, type, severity, position of pain, associated features etc), full clinical examination (signs of all the above possibilities) and relevant investigations .   Amylase, Hb (has it fallen?), wbc, U&Es, LFTs, ChestXR, ECG and troponin, U/S abdomen, echocardiogram, CT scan abdomen depending on the most likely cause. A good answer would also include what would be expected from the investigations ordered.

A large retroperitoneal  haematoma is diagnosed. After resuscitation, the bleeding is stopped by angiographic embolisation of a branch of the left internal iliac artery.
She  is  still  in  the  intensive care  unit  2  days  later  when  she  becomes suddenly dyspnoeic, hypoxaemic and hypotensive with a BP of 80 systolic.

Discussion

This woman sounds like a retroperitoneal haematoma from the very beginning, but one must go though the motions

a)        How would you investigate the cause?

A thorough history and detailed physical examination would be a good start.

Differentials:

  • Aortic dissection
  • Retroperitoneal hematoma
  • Ischaemic gut
  • perforated viscus
  • cholecystitis
  • pancreatitis
  • splenic infarct

One would assess the abdomen particularly, looking for masses.

One would auscultate the abdomen, listening for a bruit of aortic dissection

One would also look for features of shock, metabolic acidosis, and peritonism, suggestive of ischaemic gut (due to emboli dislodged from the aorta)

A CXR, ABG, ECG, a full panel of bloods including FBC, LFT, amylase/lipase and inflammatory makers.

An abdominal ultrasound looking for vascular tree damage, and a CT of the abdomen with IV contrast to image the intraabdominal organs and their supplying vessels.