MEDizzy - A 65-year-old woman with a long history of atrial

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Acute Abdominal Pain

A 65-year-old woman with a long history of atrial fibrillation presents to the emergency department with a history of sudden onset of constant, severe abdominal pain. After the onset of the pain, she vomited once and had a large bowel movement. No flatus has passed since that time. Her vital signs are: heart rate, 124 beats/min (irregular); respiration, 18/min; blood pressure, 140/60 mm Hg; temperature, 38.0°C. Physical examination reveals a mildly distended abdomen that is mildly tender diffusely. There are no peritoneal signs. Electrocardiogram reveals the patient to be in atrial fibrillation but otherwise normal. Chest radiograph is unremarkable. Ten years ago, this patient underwent a vaginal hysterectomy. Which of the following would be most appropriate in the subsequent evaluation of this patient?

ExplanationD. The triad of a cardiac arrhythmia, sudden onset of severe abdominal pain, and gut emptying is classic for embolic mesenteric ischemia. This patient's pain is also out of proportion to the physical examination, another classic sign of mesenteric ischemia. In this setting, the most appropriate initial diagnostic study should be an arteriogram of the mesenteric arterial supply to characterize the extent and location of disease. Abdominal ultrasound, computed tomography scanning, and upper endoscopy are useful in other situations in which the clinical findings are more subtle or suggestive of other specific intra-abdominal diagnoses