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. List the differential diagnosis.   Outline how you would investigate the cause of the abdominal pain.

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College Answer

The  differential   diagnosis   could  be  large  and  should  include  pancreatitis,  retroperitoneal
haematoma, aortic dissection, cholecystitis, infarcted gut, Gastro-Intestinal perforation, diverticular disease, pericarditis, myocardial infarction/ischaemia, pneumothorax, etc.
Investigation  includes, in addition to a proper history (character, type, severity, position of pain, associated features etc), and a full clinical examination (signs of all the above possibilities) a number of relevant investigations. Consider: Amylase, Haemoglobin (has it fallen?), white blood cells,  Urea  &Electrolytes,  lactate,  Liver  Function  Tests,  Chest  X-Ray,  ECG  and  troponin, ultrasound 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.

Discussion

This question closely resembles Question 2 from the first paper of 2004.

In short, 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 vessel