Chronic Abdominal Pain in a 30-Year-Old Man

[Hawkeye]

A 30-year-old white man presents to the emergency department with intermittent episodic discomfort in the upper abdomen that has lasted more than 10 years. Although the episodes are frequently severe and last several hours to 2 days, they resolve spontaneously. The patient reports no exacerbating factors, and weeks and months can pass between episodes. He is completely asymptomatic between these events. Nausea, occasional bloating, and nonbilious emesis are associated with the episodes. The patient's bowel pattern is normal, without hematochezia, and he has had no weight loss or fevers. Results of multiple evaluations in the past, including upper endoscopy and upper gastrointestinal contrast studies, have been normal.

The review of systems is otherwise unremarkable. The patient works in an office and does not smoke or drink. He takes no medications and has no allergies. The patient underwent laparoscopic cholecystectomy in the past and once had a hip fracture from a fall.

On examination, the patient is markedly uncomfortable. Abdominal palpation reveals tenderness in the epigastrium with guarding but no rebound. No masses or organomegaly are detected. Bowel sounds are normal. Findings on rectal examination are normal, with no masses and heme-negative brown stool. The patient's vital signs, remaining physical findings, and laboratory values are normal.

What is the diagnosis?

Hint
Abdominal CT is helpful in establishing the diagnosis.

[originaltup]

eu vad pe CT ceva ce pare a fi un pancreas cu calcificari, deci o pancreatita cronica, sau mai degraba calcificari daca ma uit si la istoric:colecist scos si fractura de sold ar putea fi de la un hiperparatiroidism.
La varsta asta colecistectomie ar putea sa aiba de la siclemie, dar examenul fizic zici ca e normal.
Ar mai putea fi substanta de contrast dar n-am idee in ce.
Oricum CT-ul e un pic ciudat, nu-mi dau seama f clar la ce nivel e facut (ce vertebra adica)

In concluzie, cred ca e hiperparatiroidism (desi si hipoparatiroidismul ar putea provoca calcificari ectopice dar nu se explica fractura si ar fi trebuit sa mai aiba si alte modicari)

[delu]

si in spate la pancreas ce-i? nivelul ala hidroaeric? stomacul in spate la pancreas ???

my opinion: pancreatita cronica

[originaltup]

Poate e vreo hernie hiatala

PS. m-ar ajuta daca as sti la ce nivel e facut CT-ul, caci dupa cum am zis nu imi dau seama exact

[Hawkeye]

Answer
Superior mesenteric artery syndrome: The abdominal CT scan shows marked dilatation of the proximal duodenum. At the level of the superior mesenteric artery (SMA), the third part of the duodenum is narrowed. The duodenum is compressed by a sharp aortomesenteric angle as it passes between the SMA and aorta, resulting in SMA syndrome. The distal duodenum appears normal in caliber. Initially recognized by Von Rokitansky in 1861, SMA syndrome is an uncommon cause of chronic, intermittent, or acute complete or partial duodenal obstruction. Often a diagnostic dilemma, this entity is a diagnosis of exclusion.
The patient was referred for elective surgical evaluation to discuss his candidacy for laparoscopic jejunostomy bypass.

PS: Si mie mi s-a parut CT-ul neclar...

[delu]

unde-s imagistii cu interpretarea si da raspunsul Hawkeye nu ne mai fierbe...

[originaltup]

da' numai in contratimp am fost cu voi, scriam ceva, intram sa modific si cand ieseam deja era un post dupa mine

e cam ciudat, daca e obstructia in duoden III de ce are varsaturi nebilioase? ca dupa anatomia mea coledocul se varsa in duoden II

[delu]

postat de doua ori... tampenia de back

[Hawkeye]

Cand am vazut prima data poza, mi-a zburat gandul la pancreas inelar, dar, din moment ce endoscopia nu a relevat nimic, tranzitul baritat este normal, iar nivelul hidroaeric este cam la acelasi nivel cu pancreasul, se exclude.
Chestia cu fractura e pusa la deruta, desi, pt corectitudine, trebuie mentionata. Oricum, este posibil sa aiba si tulburari in metabolismul calciului.
Dilema cu varsaturile nonbilioase... n-as putea s-o explic. Pe langa faptul ca, coledocul se varsa in D2, la pacientii colecistectomizati, apare reflux de bila in stomac. Poate a fost pusa pt a exclude din start vreo afectiune a cailor biliare.
Recunosc ca si pe mine m-a indus in eroare poza asta. Am pus niste sageti, sper sa nu fie vreo greseala; daca e, nu dati cu pietre.

[delu]

...including upper endoscopy and upper gastrointestinal contrast studies, have been normal

pai si ei pana la ce nivel avanseaza cu endoscopul, nu pana la limita duodeno-jejunala, endoscopistul trebuia sa vada..., ca sa nu mai zic de tranzitul baritat...
iar chestia asta

SMA syndrome is an uncommon cause of chronic, intermittent, or acute complete or partial duodenal obstruction

nu prea este o scuza a normalitatii endoscopiei si tranzitului intestinal...

iar asta

Often a diagnostic dilemma, this entity is a diagnosis of exclusion

m-a lasat afis

cat despre interpretarea CT

[originaltup]

btw, daca in momentul efectuarii CT-ul cu substanta de contrast se facea si o radiografie abdominala de fata, in picioare, sunt sigur ca era destul de evident sediul obstructiei (chiar daca spre deosebire de CT nu se vedea si cauza) si ar fi ajutat destul de mult la punerea diagnosticului.