A 72-year-old man with a medical history significant for chronic obstructive pulmonary disease (COPD), type 2 diabetes mellitus, hypertension, atrial fibrillation, and prior ischemic stroke is admitted for a 1-day history of worsening abdominal pain. The pain started suddenly, is constant and diffuse, and is described by the patient as 7 out of 10 in intensity. It is not associated with oral intake. The pain is not relieved by over-the-counter pain relievers and is not exacerbated with movement. He did feel some nausea and has had multiple episodes of bilious emesis, but he has not had any hematemesis, hematochezia, diarrhea, or melena. He denies having any fevers, chills, or night sweats, as well as any history of recent abdominal trauma, weight changes, or surgery. He is currently taking metformin, amiodarone, baby aspirin, extended-release metoprolol, and amlodipine. He has no allergies or family history of coronary artery disease or cancer. He drinks socially and denies any illicit drug use. He has an approximately 80 pack-year smoking history.
On physical examination, his oral temperature is 99.8°F (37.6°C). His pulse is irregularly irregular, with a rate of 95 bpm and no audible murmurs. His blood pressure is 168/95 mm Hg. He is a moderately obese, barrel-chested man in moderate distress secondary to his generalized abdominal discomfort. The head and neck examination is normal. There is no scleral or sublingual icterus. His lungs are clear to auscultation and normal respiratory effort is noted. His abdomen is soft and exhibits only diffuse mild tenderness on deep palpation. No organomegaly, rebound, guarding, or rigidity is noted. The rectal examination reveals normal tone and brown, guaiac-positive stool. The remainder of the physical examination is otherwise unremarkable.
His white blood cell (WBC) count is elevated at 16.8 × 103/µL (16.8 × 109/L; normal range: 4.2-11.0 × 103/µL), with a bandemia of 15%. The remainder of the laboratory analysis, including the basic metabolic panel, amylase, lipase, hemoglobin/hematocrit levels, lactic acid, coagulation profile, thyroid-stimulating hormone, urine analysis, and chest radiography, are normal. Initial blood and urine cultures are negative. Computed tomography (CT) of the abdomen and pelvis using oral and intravenous contrast is performed (Figures 1 and 2).
What is the diagnosis?
Hint: Recognition of this often benign condition can help avoid an unnecessary exploratory laparotomy.
A. Ruptured abdominal aortic aneurysm
B. Bowel obstruction
C. Pneumatosis intestinalis
D. Pancreatitis
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