Unusual Cause of Abdominal Pain

Abstract

Question: A 77-year-old man with atrial fibrillation presented to the emergency department with abdominal pain that had worsened over the course of 1 day. The patient had suffered a similar attack 6 months earlier and was diagnosed with mesenteric ischemia. He had received anticoagulant therapy since this first attack. Physical examination revealed mild pale conjunctiva, hypoactive bowel sounds, and mild muscle guarding over the lower abdomen without bleeding. Laboratory analysis revealed normal liver and renal function. The white blood cell count was well within the normal range, and the patient had mild anemia (hemoglobin, 10.2 g/dL). A bedside abdominal ultrasound was performed (Figure A, Video 1). Further assessment of the coagulation profile revealed a prothrombin time of >160 s (normal, 9.9-12). An abdominal computed tomography examination was subsequently performed (Figure B). What is the finding of abdominal ultrasound? What is the finding of abdominal computed tomography? Look on page 832 for the answer and see the Gastroenterology web site (www.gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI.

Progress in the ultrasonographic microvascular imaging

“…We have also used the SMI technique to aid in the diagnosis of intramural hematoma after an abdominal CT scan revealed intestinal wall thickening [ Figure 3 ] over a long section of the small intestine in a 77-year-old patient who had sought medical attention for acute abdominal pain. [ 3 ] In this case, SMI revealed that the thickened intestinal wall still had capillary blood flow [ Figure 4 ], allowing her physician to eliminate bowel ischemia as the etiology of her pain ([Figures 1 - 4 ] have been partially picked from the previous publication as noted in Reference 2 and 3). Since the patient had a history of anticoagulant use, the diagnosis of intramural hematoma of the intestine was confirmed by endoscopy [ Figure 5 ], and her symptoms improved after the patient stopped the use of anticoagulants.…”