The emergency department house staff pages you to see Ms. Panosian, a 65-year-old female, who is complaining of severe, unremitting abdominal pain. Ms. Panosian tells you the pain is sharp and diffuse and began a couple of days ago. Eating makes her pain worse. Her vitals are:
- Temperature 100.8
- BP: 140/90
- HR: 118
- RR: 24
- O2 (%): 95% on RA
When you first see her, she appears very uncomfortable, but her vocalized complaints seem out of proportion to her physical exam findings. A digital rectal exam is positive for occult blood.
You initiate your diagnostic workup. Labs are notable for a WBC of 24,000 and a lactic acid of 4.4. Her ABG shows an early metabolic acidosis. While reviewing the chart, you noticed her EKG shows atrial fibrillation.
You go back to see the patient who tells you she is on chronic anticoagulation medication but ran out last week and has not refilled her prescription. You reexamine her and she now has generalized peritonitis.
You suspect ischemic bowel.
1. Describe the physical findings associated with generalized peritonitis.
2. Based on the presence of generalized peritonitis alone, would you say that Ms. Panosian has early or late ischemic bowel?
Generalized peritonitis is inflammation of the parietal peritoneum. It can result from any inflammatory or infectious disease process that occurs in the abdomen including rupture of a hollow viscus and spillage of gastrointestinal contents, bile, blood, or bacteria.
As with all processes that involve the peritoneum, the pain in generalized peritonitis is constant and sharp. It is also associated with reflexive contraction of the abdominal wall and, on physical exam, “board-like” rigidity. Even lightly tapping on the abdominal wall will usually elicit pain. The patient will sometimes report that, on the trip to the hospital, every bump in the road was excruciating.
Ischemic bowel initially results in visceral pain—the visceral afferents of the bowel are exquisitely sensitive to ischemia. In this early phase there is no inflammation of the peritoneum and therefore no somatic pain or any signs of peritonitis. The lack of peritonitis explains the classic teaching that patients with early ischemic bowel have “pain out of proportion to physical exam.”
If the ischemia is not reversed, however, transmural inflammation and eventually necrosis will ensue. Even if the bowel doesn’t perforate, the inflammation irritates the peritoneum and therefore causes peritonitis localized to the area of the abdomen in which the bowel is ischemic. When the bowel perforates, bowel contents are spilled into the abdominal cavity, leading to generalized peritonitis. Given the progression of Ms. Panosian’s exam, she has most likely perforated and this is therefore relatively “late” ischemic bowel.
Generalized peritonitis often represents an “acute” abdomen, meaning urgent surgical intervention is mandatory. As ...