Older Woman With Recent Abdominal Pain and Fullness

December 31, 2006

On her eighth day in the hospital for acute pulmonaryembolism, an 88-year-old woman complains of nauseaand abdominal pain and fullness of 12 hours’ duration.The pain is localized to the mid epigastric area and radiatesinto the right lower quadrant. The patient deniesvomiting, melena, and dysuria; she has refused to eat allday.

On her eighth day in the hospital for acute pulmonaryembolism, an 88-year-old woman complains of nauseaand abdominal pain and fullness of 12 hours' duration.The pain is localized to the mid epigastric area and radiatesinto the right lower quadrant. The patient deniesvomiting, melena, and dysuria; she has refused to eat allday.History.Her medical history includes atherosclerosis,a remote infarct of the anterior wall, stable systolicheart failure, hypertension, and hyperlipidemia. Hermedications include intravenous unfractionated heparin;warfarin, 5 mg/d; atorvastatin, 10 mg/d; omeprazole,20 mg/d; furosemide, 40 mg/d; metoprolol, 25 mg/bid;and ramipril, 5 mg/d.Examination.The patient is anxious and is in acutedistress. Her pulse rate is 65 beats per minute; respirationrate, 15 breaths per minute; blood pressure, 125/65 mmHg; and temperature, 36.1oC (96.9oF).Marked tympany is present throughout the abdomen,with hypoactive bowel sounds. A new vague, tender,nonpulsatile fullness in the mid epigastric area is noted.Faint bibasilar crackles are audible in the lung fields.Cardiovascular examination findings are normal; no jugularvenous distension, murmurs, or gallops are detected.There are no skin changes. All other findings areunremarkable.Laboratory studies.The white blood cell count is5600/μL with a normal differential; hemoglobin, 9.9 g/dL(it had been 11.4 g/dL 2 days earlier); mean corpuscularvolume, 91 fL; and platelet count, 230,000/μL. Prothrombintime is 21.2 seconds; INR, 3.1; and partial thromboplastintime, 91 seconds. The ECG reveals poor R waveprogression, which was also found when the patient wasadmitted to the hospital.A plain abdominal radiograph is obtained.What abnormalities does the film show, and to whichof the following disorders does the clinical picturepoint?A.Diverticular abscessB.Colorectal cancerC.Retroperitoneal bleedingD.Aortic aneurysmWHAT'S WRONG:The radiographic findings are nonspecific. A psoasshadow is present on the left side but absent on the right(Figure 1).An ileus with bowel displaced to the left isnoted.In a patient who recently started anticoagulant therapy,a new abdominal mass, ileus, and worsening anemiastrongly suggest a retroperitoneal hemorrhage, C. A CTscan of the abdomen--the diagnostic test of choice inthis setting--is ordered. Ultrasound examination is nearlyas sensitive and specific as CT for diagnosis of retroperitonealbleeding and is an alternative in this setting.1What the images show.The CT slice at level L1reveals a retroperitoneal hemorrhage (Figure 2); theslice at level L5 shows a large hematoma (Figure 3).The loss of the psoas shadow in conjunction withthe ileus and displacement of bowel gas is a classic radiographicpattern of a retroperitoneal fluid collection. Thefluid obscures the interface of muscle and fat that normallyappears as a crisp psoas shadow line (see Figure2). However, the absence of one or both psoas shadowson a plain film does not necessarily indicate a pathologiccondition; rotation of the fat-muscle interface and scoliosis(especially on the convex side) can obscure theseshadows.1 The clinical clue to the diagnosis of retroperitonealbleeding in this patient is the recent initiation ofanticoagulation.A CASE IN POINTClinical features.The presentation of retroperitonealhemorrhage can be equivocal and may belie the potentiallylife-threatening disease process. Nausea, abdominal fullness,and anemia are nonspecific findings that are frequentlyseen in hospitalized patients.Causes.Retroperitoneal hemorrhages can resultfrom trauma, vascular procedures, and rupture of an aorticor a renal artery aneurysm. Benign or malignant tumorsof the adrenal glands and kidneys can also cause hemorrhagesspontaneously or after anticoagulants have been initiated.Retroperitoneal bleeding may occur spontaneouslyin 4% to 7% of patients who receive anticoagulants and 3%of patients who are on long-term hemodialysis.2Treatment. Management consists of hemodynamicsupport, discontinuation of anticoagulants, and reversal ofblood dyscrasias; emergent laparotomy may be necessaryif hemodynamic stability cannot be achieved medically.Outcome of this case. The anatomic source of thispatient's retroperitoneal bleeding was not discovered. Heranticoagulants were discontinued; fresh frozen plasma wasadministered. Because this patient's recent pulmonary embolismplaced her at very high risk for repeated thromboembolism,a venocaval filter was placed.Two days later, her hemoglobin level was 7.8 g/dL.She responded clinically to the infusion of 2 units ofpacked red blood cells. The remainder of her recoverywas uneventful; she was discharged from the hospital 4days later.

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1.

Bloom RA, Gheorghiu D, Verstandig A, et al. The psoas sign in normal subjectswithout bowel preparation: the influence of scoliosis on visualisation.

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1990;41:204-205.

2.

Pode D, Caine M. Spontaneous retroperitoneal hemorrhage.

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1992;147:311-318.