Best Doctors

Physician Webinars

Case Studies in Diagnostic Errors:

Our Errors in Diagnosing Abdominal Pain

Deepak Bhatt, MD, MPH Senior Physician, Cardiovascular Medicine, Brigham and Women's Hospital Professor, Harvard Medical School

Norton Greenberger, MD Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital Clinical Professor of Medicine, Harvard Medical School

Martin Samuels, MD, MSc, FAAN, MACP, FRCP Chairman, Department of Neurology, Brigham and Women’s Hospital Professor of Neurology, Harvard Medical School

Moderator and Panel

Tonight 3 things you need to know

• Best Doctors provides medical consultations/second opinions through a unique and collaborative analytical process

• If you are an elected Best Doctor you are invited to consult on cases (and earn an honorarium)

• Free pilot program – physicians may initiate collaborations on their complex cases

Abdominal Pain Dr. Martin Samuels

37 Year Old Man with Abdominal Pain

• 37 year old man complained of left lower quadrant abdominal pain for about six months

• The pain radiated from the left flank, down along the inguinal ligament and into the left testicle

• The pain was usually not there on awakening but worsened as the day progressed

• Jogging greatly worsened the pain

37 Year Old Man

• The abdomen was non-tender

• No masses could be palpated

• Liver was normal size

• Spleen non-palpable

• No bruits heard

• A well healed appendectomy incision (done at age 23)

• Some numbness around the incision

• Rectal exam normal; guaiac negative

37 Year Old Man Workup

• Renal ultrasound normal

• Urinalysis repeatedly normal

• Abdominal and pelvic CT normal

37 Year Old Pain

• Lidocaine injection at the edge of the incisional scar at the iliac crest relieved the pain temporarily but it returned unchanged

• A consultation was obtained

37 Year Old Man

• Neuromuscular specialist diagnosed an iliohypogastric nerve entrapment

• The incision was explored and the nerve released

• The symptoms resolve, never to return

• Nerve arises from T12 and L1

• Referred pain accounts for symptoms, which imitate renal colic

Iliohypogastric Nerve

Iliohypogastric Nerve Block

From Medscape

Needle entry for iliohypogastric nerve block

Needle entry point for genital branch genisofomoral nerve

Anterior superior

Needle entry for XXX nerve block

Public tubercle

Abdominal Pain Dr. Norton Greenberger

M.S. 37 y/o Female MGH 2010

• Unexplained illness, Fever, Chills, Nausea, Fatigue, Diarrhea since late 2009

• Unremarkable physician exam

• Extensive Work up

Summary of Prior Laboratory, Endoscopy and Imaging Studies

2009-2011 Negative/Normal Laboratory:

Cultures: urine, blood stool (-) HIV, Lyme, CMV, Viral Hepatitis markers TSH, FT4 Prolactin Serum Serum tryptase ACTH stimulation x 2 NL Urine Catecholamines

Urine 5 HIAA CMP 20 ESR, CRP ANA + 1:320 C-1-esterase TTG – AB (-) SSA SSB Sjögren (-) Octreotide scan (-)

Imaging:

• Head CT

• Head MRI

• Abdomen MRI

• Chest CT

• Cardiac stress echo normal

Endoscopy:

EGD (-)

Hypotensive after EGD

Initial BWH Work Up

History:

• Flushing

• Headaches

• Sweats

• Forget fullness

• Occasional abdominal pain and distension

• Inordinate fatigue

• Alcohol intolerance

• Red skin after hot shower

• POTS syndrome on Rx 2-4 liter fluid 1-2gm/NaC1/day

Physical Examination:

• T-98; P 78; BP 113/67; WT 170

• Skin: Marked dermatographism Mantle flush

• Lungs: Clear

• Cardiac: NSR, no murmers

Abdomen:

• Liver 11cm - ↓ 2-3 cm

• Extremties No c,c,e

• Neuro: Sluggish DTRs

Impression: MCAS

M.S. Orthostatic Tachycardia

10/14/2010

Heart Rate

Supine 75

Tilt Table 107 after 6’

Baseline 78

Standing 3’ 116

Exaggerated postural tachycardia

Valsalva maneuver – Normal heart rate and blood pressure response

24 hour urine

N-methyl histamine 96 (<200)

Prostaglandin F2 867 (<1000)

Labs:

Rx:

• Loratidine 10mg/b.i.d.

• Ranitidine 150mg/b.i.d.

• Singulair 10mg/q.d.

• Cromolyn 200 mg/q.i.d.

Pt. MS follow up May 2012

• *flushing minimal

• *headache occasional

• *sweats minimal

• *mental fog 2-3/10 point scale

• *inordinate fatigue persists

• *abdominal pain minimal

• *diarrhea none

• *menses,heat, exercise -accentuate Sx’s

Mast Cell Activation Syndrome History – Typical *Unexplained flushing-mantle distribution *Alcohol intolerance *Symptoms triggered by aspirin, NSAIDS, opiates *Exposure to hot and cold temperatures *Abdominal pain with/without diarrhea History – Additional Symptoms *Headaches *Irritability *Sweating *Difficulty expressing oneself *Lack of ability to concentrate *Mood changes Presentation on Physical Exam *Dermatographism, flushing *Labs: serum tryptase, urine *Sites of abdominal pain (RLQ, LLQ) histamine and prostaglandin D2/F2 Treatment *Responds to H1 & H2 blockers, cromolyn, and singulair

Abdominal Pain in a Post-Operative

Vascular Surgery Patient

Deepak L. Bhatt MD, MPH, FACC, FAHA, FSCAI, FESC

Senior Physician, Brigham and Women’s Hospital

Senior Investigator, TIMI Study Group

Professor of Medicine, Harvard Medical School

Disclosure for Dr. Bhatt

Advisory Board: Elsevier Practice Update Cardiology, Medscape Cardiology,

Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of

Chest Pain Centers; Chair: American Heart Association Get With The Guidelines

Steering Committee; Honoraria: American College of Cardiology (Editor, Clinical

Trials, Cardiosource), Belvoir Publications (Editor in Chief, Harvard Heart Letter),

Duke Clinical Research Institute (Clinical Trial Steering Committees), Population

Health Research Institute (Clinical Trial Steering Committee), Slack Publications

(Chief Medical Editor, Cardiology Today’s Intervention), WebMD (CME Steering

Committees); Other: Senior Associate Editor, Journal of Invasive Cardiology; Data

Monitoring Committees: Duke Clinical Research Institute, Mayo Clinic, Population

Health Research Institute; Research Grants: Amarin, AstraZeneca, Bristol-Myers

Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company;

Unfunded Research: FlowCo, PLx Pharma, Takeda.

This presentation discusses off-label and/or investigational uses of various drugs

and devices.

Case

• 78 year old male with abdominal pain post-op day #2

after R-sided fem-pop for rest pain in right foot.

PMH

• HTN x 30 years

• Diabetes diagnosed 20 years ago

• Former smoker; quit 10 years ago; >50 pack-years

• COPD x 10 years

• Peripheral artery disease – R foot pain at rest; found

to have long occlusion of R SFA with poor

collateralization. Referred for fem-pop bypass.

Medications

• Aspirin 81 mg daily

• Metformin 1000 mg BID

• Ramipril 5 mg daily

• Metoprolol XL 100 mg daily (recently increased from

50 mg)

• HCTZ 25 mg daily

• Simvastatin 20 mg daily

• Inhalers – prescribed, but not taking

• NKDA

Social History

• Married. Two grown children. Retired engineer.

Smoking history as above. Occasional ETOH.

Operative Course

• General anesthesia

• Episode of transient hypotension, otherwise

unremarkable

HPI

• POD #2, doing well from vascular surgery perspective

• Extubated, on RA with O2 sat of 92%

• BP 90/50, HR 50, RR 14, T 99.2

• Complains of nausea, 1 episode of emesis

• ROS positive for abdominal pain

• Exam notable for

– Decreased breath sounds, but no wheezing

– No murmurs

– + BS. Mild RUQ tenderness on deep palpation

– No edema. Moderate sized hematoma at R femoral

arteriotomy site with moderate tenderness

Course

• Blood cultures sent

• Ultrasound of gallbladder ordered

• Anti-emetics ordered with relief

• Morphine ordered for pain from hematoma

• Systolic blood pressure running 85-90 mmHg with HR

45-50

– Felt to be vagal from abdominal pain and from

hematoma

– 500 cc NS bolus x2 ordered

Course

• U/S of gallbladder done, shows thickened gallbladder

walls and slight distention of gallbladder

• Systolic blood pressure post bolus low 80s

• Abdominal discomfort persists

Course

• ECG recommended

– Sinus bradycardia at 48. No ST elevation noted.

• Cardiac biomarkers sent

• Biomarkers return – positive troponin

• ECG repeated

– 2-3 mm ST depression in inferior leads (prior ECG

on review showed ~1 mm ST depression in inferior

leads)

– Cardiology consulted

– Patient taken to cath lab – 95% stenosis of mid RCA

prior to a large RV marginal branch successfully

stented

Lessons

• Ischemia can manifest as abdominal discomfort,

classically inferior (RCA) ischemia.

• Ischemia can cause hypotension and bradycardia.

• RV ischemia can be profound and refractory to initial

fluid resuscitation.

• Be wary for post-operative ischemia, especially in

patients at high CV risk (even if “cleared” for surgery).

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