Abdominal Pain and Hypotension in a 70-Year-Old Woman
Educational Objective
Based on this clinical scenario and the accompanying image, understand how to arrive at a correct diagnosis.
A 70-year-old woman with hypertension, atrial fibrillation, congestive heart failure, and gallstones presented to the emergency department with 3 days of nausea, vomiting, and abdominal pain. She reported no hematemesis, hematochezia, or melena and had no history of abdominal surgery. On admission to the emergency department, she was afebrile, her blood pressure was 80/60 mm Hg, and heart rate was 122/min. On physical examination, her abdomen was distended, tympanic, and slightly tender to palpation diffusely. Blood testing showed a white blood cell count of 10 450/μL (84.1% neutrophils); C-reactive protein level, 9.5 mg/dL; potassium level, 3.0 mEq/L (reference, 3.6-5.2 mEq/L); and creatinine level, 5.57 mg/dL (429.39 μmol/L, up from a baseline level of 0.80 mg/dL [70.72 μmol/L]). Sodium and liver function values were normal.
In the emergency department, she received a 500-mL bolus of intravenous crystalloid fluid and 1 g of intravenous ceftriaxone. A nasogastric tube was placed and initially drained 300 mL of biliary fluid.
A non–contrast-enhanced abdominal computed tomography (CT) scan was performed (Figure 1).
Figure 1.
What Would You Do Next?
- Administer barium through the nasogastric tube to evaluate for bowel obstruction
- Order magnetic resonance cholangiopancreatography
- Perform an emergency explorative laparotomy
- Plan for surgical intervention after intravenous fluid resuscitation in the intensive care unit (ICU)
