100 Cases in Clinical Medicine

CASE 94: ABDOMINAL PAIN

History

A 70-year-old woman is admitted to hospital with acute onset of abdominal pain. The
abdominal pain started quite suddenly 24 h before admission and has continued since then.
It is a constant central abdominal pain. She has vomited altered food on one occasion.

She has a history of occasional angina on exertion for 5 years. She has a glyceryl trinitrate
spray but she has not needed this in the last 3 months. A year ago she was found to be in
atrial fibrillation at 120/min, and she was started on digoxin, which she still takes. The only
other medical history of note is that she had a hysterectomy for menorrhagia 30 years ago
and she has hypertension controlled on a small dose of a thiazide diuretic for the last
3 years. She does not take any other medication apart from low-dose aspirin. She does not
smoke and does not drink alcohol. She retired from work as a cleaner 8 years ago.

Examination

She was in atrial fibrillation at a rate of 92/min with a blood pressure of 114/76 mmHg.
Respiratory examination was normal. She was tender with some guarding in the centre of
the abdomen. No masses were palpable in the abdomen and there were just occasional bowel
sounds to hear on auscultation. Over the next 2 h the blood pressure fell to 84/60 mmHg. She
was admitted to the intensive care unit (ICU) and monitored while initial investigations were
performed. The abdominal X-ray showed no gas under the diaphragm and no dilated loops
of bowel or fluid levels. While under observation, the urine output fell off. Re-examination
showed that bowel sounds were absent. Her hands and feet remained warm. Measurements
of cardiac output in ICU showed that it remained high.

The observation charts are shown in Fig. 94.1.

INVESTIGATIONS

40

39

38

37

36

35

34

100

8

4

CVP

(mmHg)

Blood

pressure

(mmHg)

Temperature
(°C)

12345

Hours

Central

temperature

Central venous

pressure

Blood pressure

Peripheral

temperature

Pulse

Figure 94.1Chart from intensive care unit.

Questions

• What is the likely cause of the abdominal pain?


• What further developments do the charts suggest?