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?
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.
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:
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.