Emergency. 2016; 4 (3): 166-168 PH OTO QU I Z A 33-year-old Man with Abdominal Pain Kuo-Chih Chen1, Aming Chor-Ming Lin1,2,3, Chin-Chu Wu4, Tzong-Luen Wang1,3, Chai-Hock Chua1∗ 1. Emergency Department, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 2. Department of Intensive Care Unit, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 3. School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan. 4. Department of Medical Imaging, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. 5. Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan. Received: January 2016; Accepted: March 2016 Cite this article as: Chen K, Lin A, Wu Ch, Wang T, Ch Ch. A 33-year-old Man with Abdominal Pain. Emergency. 2016; 4(3):166-168. Figure 1: Patient’s abdominal imaging. 1. Case presentation: A 33-year-old man presented to the emergency department ED) with complaint of 2-day history of abdominal pain. His pain developed with gradual onset prominently in epigastric area after eating dried mushrooms. The pain was diffuse, persistent, radiating to the back and aggravated by meal. He had been tolerating only liquids and had complaints of nausea and vomiting. He had no history of diabetes mellitus, hypertension, alcohol consumption, malignancy, or prior surgery. On arrival his blood pressure was 128/72 mmHg, with a heart rate of 101 beats/minute and a respiratory rate ∗Corresponding Author: Chai-Hock Chua; Division of Cardiovascular Surgery, Department of Surgery, Shin Kong Wu Ho-Su Memorial Hospital, 95 Wen Chang Rd, Taipei 111, Taiwan. Tel: 886-02-28332211 Ext 2082 / Fax: 886- 02-28353547; E-mail: M002001@ms.skh.org.tw of 20 breaths/minute. He was afebrile. Physical exami- nation revealed diffuse abdominal distention, hyper-pitched bowel sounds, and tenderness more marked over the um- bilicus with no guarding or rebound tenderness. A complete blood cell count showed the following: leukocyte count 12600 /mm3; segmented neutrophils 90%; hemoglobin level of 14 mg/dl; hematocrit 30%; and platelet 420000/µ L. Other laboratory studies included: glucose 101 mg/dL; serum urea nitrogen 45 mg/dL; serum creatinine 2.0 mg/dL; sodium 148 mEq/L; potassium 3.1 mEq/L; serum glutamic oxaloacetic transaminase (SGOT) 38 U/L and lipase 30 U/L. Figure 1 shows patient’s plain upright abdominal X-ray as well as coronal and axial cuts of abdominal CT scan. What is your diagnosis? This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com 167 Emergency. 2016; 4 (3): 167-168 Figure 2: Patient’s abdominal computed tomography scan. 2. Diagnosis: Abdominal CT scan showed multiple masses with peculiar shape (Figure 2, arrows) in stomach and ileum. Post contrast CT scan showed peculiar shape masses impacting the bowel on the middle side of the abdomen with dilated small intes- tine above that level. The CT scan finding was consistent with evidence of a mechanical obstruction. 3. Case fate: The patient underwent conservative treatment such as naso- gastric suction, decompression, aggressive intravenous flu- ids, bowel rest and antibiotics for 3 days. The undigested mushrooms had passed through feces later. He had an un- eventful recovery with no complications. 4. Discussion: Intestinal obstruction is a relatively common problem en- countered in the ED, accounting for an estimated 15% of all emergency admissions for abdominal pain (1-4). Delayed diagnosis of small bowel obstruction is still associated sig- nificant and morbidity and mortality. Early diagnosis and identification of the cause of obstruction has importance in therapeutic management (5). The diagnosis may be suspected based upon clinical history, presentation, physical examination and radiologic findings. Abdominal pain and distention is the hallmark of all forms of intestinal obstruc- tion, and constipation, nausea and vomiting are the most common symptoms. Tympany to percussion and hyper- pitched bowel sounds are the classic physical examination findings (6, 7). Although adhesion band and incarcer- ated hernia are among the most common causes of small bowel obstruction, bezoars and ingested materials could be considered as less common causes (1, 8). Bezoars are concretions of indigested or partially digested material in the gastrointestinal tract which divided to different types in- cluding phytobezoars, trichobezoars, pharmacobezoars and lactobezoars. An important cause of phytobezoars is dried fruits (9, 10). Predisposing factors include previous gastric surgery, inadequate chewing, excessive consumption of fruits rich in fibers, renal insufficiency, hypothyroidism, and chronic constipation (11). The initial evaluation of patients with clinical signs and symptoms of intestinal obstruction should included plain upright abdominal radiography. Ab- dominal CT scan can help to confirm the diagnosis of small bowel obstruction and identify strangulation and perfora- tion complicating small bowel obstruction (12, 13). The bezoar could be seen on the CT scan examination. Intestinal obstruction caused by bezoar not only requires immediate treatment but also recognition of underlying cause of bezoar formation (14, 15). The presence of peritoneal irritation signs usually indicates late obstruction with complications, including vascular compromise or perforation. Failure to resolve with adequate bowel decompression is an indication for surgical intervention. The findings of peritonitis, clinical instability, persistent abdominal pain are concerning for intra-abdominal sepsis, intestinal ischemia, or perforation, which mandate immediate surgical exploration (16). This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com K. Chen et al. 168 5. Appendix 5.1. Acknowledgements We would like to express our special thanks to Shin Kong Wu Ho-Su Memorial Hospital staff. 5.2. Conflict of interest None declared. 5.3. Funding and support None declared. 5.4. Authors contributions All authors passed four criteria for authorship contribution based on recommendations of the International Committee of Medical Journal Editors. References 1. Jackson PG, Raiji M. Evaluation and management of intestinal obstruction. American family physician. 2011;83(2). 2. Kariman H, Shojaee M, Sabzghabaei A, Khatamian R, Derakhshanfar H, Hatamabadi H. Evaluation of the Al- varado score in acute abdominal pain. Ulus Travma Acil Cerrahi Derg. 2014;20(2):86-90. 3. Majidi A, Mahmoodi S, Baratloo A, Mirbaha S. Atypical Presentation of Massive Pulmonary Embolism, a Case Report. Emergency. 2014;2(1):46. 4. Forouzanfar M, Hatamabadi H, Hashemi B, Majidi A, Baratloo A, Shahrami A, et al. Outcome of nonspecific ab- dominal pain in the discharged patients from the emer- gency department. Journal of Gorgan University of Med- ical Sciences. 2014;16(2):62-8. 5. Schwab DP, Blackhurst DW, Sticca RP, Laws II HL. Op- erative acute small bowel obstruction: Admitting ser- vice impacts outcome/Discussion. The American sur- geon. 2001;67(11):1034. 6. Mullan CP, Siewert B, Eisenberg RL. Small bowel obstruction. American Journal of Roentgenology. 2012;198(2):W105-W17. 7. Shin C-I. Small Bowel Obstruction. Radiology Illustrated: Gastrointestinal Tract: Springer; 2015. p. 325-49. 8. 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Computed Tomography Findings of Small Bowel Obstruction due to Bezoar Impaction: A Case Se- ries. Emergency Medicine: Open Access. 2012;2012. 14. Wang P-Y, Wang X, Zhang L, Li H-F, Chen L, Wang X, et al. Bezoar-induced small bowel obstruction: Clinical characteristics and diagnostic value of multi-slice spiral computed tomography. World journal of gastroenterol- ogy: WJG. 2015;21(33):9774. 15. Porter DJ, Cosgrove C, Middleton E. An Unusual Case of Small Bowel Obstruction. Journal of Medical Cases. 2015;6(11):517-9. 16. Paulson EK, Thompson WM. Review of small-bowel ob- struction: the diagnosis and when to worry. Radiology. 2015;275(2):332-42. This open-access article distributed under the terms of the Creative Commons Attribution NonCommercial 3.0 License (CC BY-NC 3.0). Downloaded from: www.jemerg.com Case presentation: Diagnosis: Case fate: Discussion: Appendix References