Sudden Onset of Severe Left-Sided Abdominal Pain

Abstract

A 65-year-old obese male presents to the emergency department with sudden onset of severe left-sided abdominal pain that radiates to the left flank and back. The pain began 2 h ago and started while he was watching television. He has never had the pain before. He denies any nausea or vomiting, changes in bowel habits, or bloody/black stools. Past history is significant for COPD and well-controlled hypertension. He does not drink alcohol but has smoked 1 pack per day for 35 years. On physical exam, BP is 90/60 mmHg, heart rate is 120 bpm, RR is 24, and he is afebrile. He appears to be in moderate distress secondary to pain and has diaphoresis. The lungs are clear bilaterally to auscultation without rales or rhonchi. Cardiac exam reveals a regular rate and rhythm without murmurs, rubs, or gallops. His abdomen appears pale and is moderately tender to palpation diffusely but worse in the mid-abdomen and in the left lower quadrant. He has no rebound or guarding. A palpable tender pulsatile mass is felt in the midline just above the umbilicus. Rectal exam reveals no blood, stool, or masses. Femoral, popliteal, and pedal pulses are 1+ bilaterally. Laboratory examination reveals a hemoglobin of 10.1 g/dL (normal 12.3–15.7 g/dL), hematocrit of 30.3 % (37–46 %), and WBC of 11 × 10³/μL (4.1–10.9 × 10³/μL). His AST and ALT are 30 u/L (5–35 u/L) and 45 u/L (7–56 u/L), respectively. The patient’s lipase is 50 u/L (7–60 u/L) and amylase is 62 u/L (30–110 u/L).