A Patient with Chronic Pancreatitis, Requesting Demerol

March 9, 2019

A 47 y/o woman with cirrhosis, HCV, and chronic pancreatitis requests Demerol for the worst abdominal pain she has ever had. What's your diagnosis? 

History
A 47-year-old woman with a history of cirrhosis, hepatitis C, and chronic pancreatitis presents to the emergency department for abdominal pain. The abdominal pain is diffuse and radiates to the back. She denies any fever, vomiting, or change in her chronic diarrhea. She requests a pain shot, preferably Demerol if it is available.

Examination
Vital signs are all normal. During your physical examinatino you note voluntary guarding in the epigastric area without rebound. The rest of the exam is normal. The patient states, “This is the worst the pain has ever been,” so you decide to order an abdominal CT scan along with routine abdominal laboratory tests.

Initial Concerns

  • Drug seeking behavior

  • Chronic pancreatitis

  • Lots of other less likely stuff

Testing
Results of a CBC, basic metabolic panel, serum lipase measure, and LFTs are all normal. Image of CT scan is shown in Figure 1 above (please click on image to enlarge).

Questions

  • What does the CT show?

  • What can cause this?

Please click here for answers, discussion, and case conclusion.

Answers

  • What does the CT show?  Trace ascites (scattered dark gray areas) and diffuse mildly thickened bowel wall, both of which were unchanged from her most recent prior CT at your institution.

  • What can cause this? See discussion below and highlighted area of sample page (Figure 2) at right (please click on image to enlarge).

Discussion

Bowel wall thickening has a number of potential causes, some dangerous and others less so. The normal thickness of the bowel wall is <2mm; >3mm is considered abnormal; and 2-3mm is the equivocal range. Most causes of thickened bowel wall are infectious or inflammatory (predominantly Crohn disease and ulcerative colitis) and these both typically present with diarrhea. Small bowel obstructions can cause bowel thickening and this may be a sign of ischemia. Ascites and/or portal hypertension can cause chronic bowel wall thickening, which is usually benign and is likely the cause in this case. Refer to Figure 2 for other, less common causes.

Conclusion

Patient was sent home without opiates.