CASE
An 88-year-old white female came to the emergency department (ED) complaining of acute left upper-quadrant abdominal pain that had been present for 4 hours. The pain, which was not associated with or exacerbated by food ingestion, had begun gradually and gotten progressively worse. She described it as 10 on a 10-point scale. The pain was colicky in character and did not radiate. She had no associated nausea, vomiting, diarrhea, fever, dyspnea, or dysuria.
History The medical history was significant for ongoing insulin therapy for type 2 diabetes; hypertension; and cardiac dysrhythmia, which
was well-controlled with a beta-blocker. Approximately 2 weeks earlier, the patient had been evaluated in the same ED for dehydration. Four years before this evaluation, she had been treated in a distant hospital for pancreatitis secondary to a stricture of "the opening into the bowel." Her husband described a procedure that was probably a sphincterotomy of the ampulla; there had been no subsequent recurrences of pancreatitis. The patient had no history of coronary vessel disease, although there had been a prior diagnosis of hypertrophic cardiomyopathy. In the late 1940s, the patient had undergone a partial thyroidectomy and cholecystectomy. Following a diagnosis of uterine sarcoma in the 1950s, she had undergone a hysterectomy and radiation therapy; she subsequently developed chronic bouts of diarrhea that continued
to the present and were somewhat controlled with diphenoxylate/atropine.
Physical examination The patient was a well-developed, afebrile, obese female. Except for a rapid pulse rate, vital signs were normal. She was most comfortable when sitting flexed forward; occasionally, intense pain forced her into an upright sitting position. There was no icterus of the sclera. Her heart rate was tachycardic with normal rhythm; no extra heart sounds, murmurs, or rubs were heard. Her abdomen was protuberant but not tense. Initial tenderness in the left upper quadrant was associated with guarding but not rebound. Bowel sounds were hypoactive. Rectal examination was not performed; results of a previous screening colonoscopy were normal. A CBC revealed a WBC count of 17,000/µL; hemoglobin, 10.7 g/dL; and hematocrit, 34.8%. Urinalysis detected leukocyte esterase. Other laboratory values included amylase, 39 U/L; glucose, 276 mg/dL; sodium, 137 mEq/L; potassium, 3.7 mEq/L; ALT, 112 U/L; AST, 163 U/L; and total bilirubin, 1.46 mg/dL.
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