1. Best Doctors
Physician Webinars
Case Studies in Diagnostic Errors:
Our Errors in Diagnosing Abdominal Pain

2. Deepak Bhatt, MD, MPH
Senior Physician, Cardiovascular Medicine, Brigham and Women's Hospital
Professor, Harvard Medical School
Norton Greenberger, MD
Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital
Clinical Professor of Medicine, Harvard Medical School
Martin Samuels, MD, MSc, FAAN, MACP, FRCP
Chairman, Department of Neurology, Brigham and Women’s Hospital
Professor of Neurology, Harvard Medical School
Moderator and Panel

3. Tonight 3 things you need to know
• Best Doctors provides medical consultations/second opinions
through a unique and collaborative analytical process
• If you are an elected Best Doctor you are invited to consult on
cases (and earn an honorarium)
• Free pilot program – physicians may initiate collaborations on
their complex cases

4. Abdominal Pain
Dr. Martin Samuels

5. 37 Year Old Man with Abdominal Pain
• 37 year old man complained of left lower
quadrant abdominal pain for about six months
• The pain radiated from the left flank, down
along the inguinal ligament and into the left
testicle
• The pain was usually not there on awakening
but worsened as the day progressed
• Jogging greatly worsened the pain

6. 37 Year Old Man
• The abdomen was non-tender
• No masses could be palpated
• Liver was normal size
• Spleen non-palpable
• No bruits heard
• A well healed appendectomy incision (done at
age 23)
• Some numbness around the incision
• Rectal exam normal; guaiac negative

7. 37 Year Old Man Workup
• Renal ultrasound normal
• Urinalysis repeatedly normal
• Abdominal and pelvic CT normal

8. 37 Year Old Pain
• Lidocaine injection at the edge of the
incisional scar at the iliac crest relieved the
pain temporarily but it returned unchanged
• A consultation was obtained

9. 37 Year Old Man
• Neuromuscular specialist diagnosed an
iliohypogastric nerve entrapment
• The incision was explored and the nerve
released
• The symptoms resolve, never to return
• Nerve arises from T12 and L1
• Referred pain accounts for symptoms, which
imitate renal colic

10. Iliohypogastric Nerve

11. Iliohypogastric Nerve Block
From Medscape
Needle entry for
iliohypogastric nerve
block
Needle entry point
for genital branch
genisofomoral nerve
Anterior superior
Needle entry for XXX
nerve block
Public tubercle

12. Abdominal Pain
Dr. Norton Greenberger

13. M.S. 37 y/o Female MGH 2010
• Unexplained illness, Fever, Chills, Nausea,
Fatigue, Diarrhea since late 2009
• Unremarkable physician exam
• Extensive Work up

14. Summary of Prior Laboratory,
Endoscopy and Imaging Studies
2009-2011 Negative/Normal Laboratory:
Cultures: urine, blood stool
(-) HIV, Lyme, CMV, Viral
Hepatitis markers
TSH, FT4 Prolactin
Serum
Serum tryptase
ACTH stimulation x 2 NL
Urine Catecholamines
Urine 5 HIAA
CMP 20
ESR, CRP
ANA + 1:320
C-1-esterase
TTG – AB (-)
SSA SSB Sjögren (-)
Octreotide scan (-)

15. Imaging:
• Head CT
• Head MRI
• Abdomen MRI
• Chest CT
• Cardiac stress echo
normal
Endoscopy:
EGD (-)
Hypotensive after EGD

16. Initial BWH Work Up
History:
• Flushing
• Headaches
• Sweats
• Forget fullness
• Occasional abdominal pain and distension
• Inordinate fatigue
• Alcohol intolerance
• Red skin after hot shower
• POTS syndrome on Rx 2-4 liter fluid 1-2gm/NaC1/day

17. Physical Examination:
• T-98; P 78; BP 113/67; WT 170
• Skin: Marked dermatographism Mantle flush
• Lungs: Clear
• Cardiac: NSR, no murmers
Abdomen:
• Liver 11cm - ↓ 2-3 cm
• Extremties No c,c,e
• Neuro: Sluggish DTRs
Impression: MCAS

18. M.S. Orthostatic Tachycardia
10/14/2010
Heart Rate
Supine 75
Tilt Table 107 after 6’
Baseline 78
Standing 3’ 116
Exaggerated
postural
tachycardia
Valsalva maneuver – Normal heart rate and blood
pressure response

19. 24 hour urine
N-methyl histamine 96 (<200)
Prostaglandin F2 867 (<1000)
Labs:

20. Rx:
• Loratidine 10mg/b.i.d.
• Ranitidine 150mg/b.i.d.
• Singulair 10mg/q.d.
• Cromolyn 200 mg/q.i.d.

21. Pt. MS follow up May 2012
• *flushing minimal
• *headache occasional
• *sweats minimal
• *mental fog 2-3/10 point scale
• *inordinate fatigue persists
• *abdominal pain minimal
• *diarrhea none
• *menses,heat, exercise -accentuate Sx’s

22. Mast Cell Activation Syndrome
History – Typical
*Unexplained flushing-mantle distribution
*Alcohol intolerance
*Symptoms triggered by aspirin, NSAIDS, opiates
*Exposure to hot and cold temperatures
*Abdominal pain with/without diarrhea
History – Additional Symptoms
*Headaches *Irritability
*Sweating *Difficulty expressing oneself
*Lack of ability to concentrate *Mood changes
Presentation on Physical Exam
*Dermatographism, flushing *Labs: serum tryptase, urine
*Sites of abdominal pain (RLQ, LLQ) histamine and prostaglandin D2/F2
Treatment
*Responds to H1 & H2 blockers, cromolyn, and singulair

23. Abdominal Pain in a Post-Operative
Vascular Surgery Patient
Deepak L. Bhatt MD, MPH, FACC, FAHA, FSCAI, FESC
Senior Physician, Brigham and Women’s Hospital
Senior Investigator, TIMI Study Group
Professor of Medicine, Harvard Medical School

24. Disclosure for Dr. Bhatt
Advisory Board: Elsevier Practice Update Cardiology, Medscape Cardiology,
Regado Biosciences; Board of Directors: Boston VA Research Institute, Society of
Chest Pain Centers; Chair: American Heart Association Get With The Guidelines
Steering Committee; Honoraria: American College of Cardiology (Editor, Clinical
Trials, Cardiosource), Belvoir Publications (Editor in Chief, Harvard Heart Letter),
Duke Clinical Research Institute (Clinical Trial Steering Committees), Population
Health Research Institute (Clinical Trial Steering Committee), Slack Publications
(Chief Medical Editor, Cardiology Today’s Intervention), WebMD (CME Steering
Committees); Other: Senior Associate Editor, Journal of Invasive Cardiology; Data
Monitoring Committees: Duke Clinical Research Institute, Mayo Clinic, Population
Health Research Institute; Research Grants: Amarin, AstraZeneca, Bristol-Myers
Squibb, Eisai, Ethicon, Medtronic, Sanofi Aventis, The Medicines Company;
Unfunded Research: FlowCo, PLx Pharma, Takeda.
This presentation discusses off-label and/or investigational uses of various drugs
and devices.

25. Case
• 78 year old male with abdominal pain post-op day #2
after R-sided fem-pop for rest pain in right foot.

26. PMH
• HTN x 30 years
• Diabetes diagnosed 20 years ago
• Former smoker; quit 10 years ago; >50 pack-years
• COPD x 10 years
• Peripheral artery disease – R foot pain at rest; found
to have long occlusion of R SFA with poor
collateralization. Referred for fem-pop bypass.

27. Medications
• Aspirin 81 mg daily
• Metformin 1000 mg BID
• Ramipril 5 mg daily
• Metoprolol XL 100 mg daily (recently increased from
50 mg)
• HCTZ 25 mg daily
• Simvastatin 20 mg daily
• Inhalers – prescribed, but not taking
• NKDA

28. Social History
• Married. Two grown children. Retired engineer.
Smoking history as above. Occasional ETOH.

29. Operative Course
• General anesthesia
• Episode of transient hypotension, otherwise
unremarkable

30. HPI
• POD #2, doing well from vascular surgery perspective
• Extubated, on RA with O2 sat of 92%
• BP 90/50, HR 50, RR 14, T 99.2
• Complains of nausea, 1 episode of emesis
• ROS positive for abdominal pain
• Exam notable for
– Decreased breath sounds, but no wheezing
– No murmurs
– + BS. Mild RUQ tenderness on deep palpation
– No edema. Moderate sized hematoma at R femoral
arteriotomy site with moderate tenderness

31. Course
• Blood cultures sent
• Ultrasound of gallbladder ordered
• Anti-emetics ordered with relief
• Morphine ordered for pain from hematoma
• Systolic blood pressure running 85-90 mmHg with HR
45-50
– Felt to be vagal from abdominal pain and from
hematoma
– 500 cc NS bolus x2 ordered

32. Course
• U/S of gallbladder done, shows thickened gallbladder
walls and slight distention of gallbladder
• Systolic blood pressure post bolus low 80s
• Abdominal discomfort persists

33. Course
• ECG recommended
– Sinus bradycardia at 48. No ST elevation noted.
• Cardiac biomarkers sent
• Biomarkers return – positive troponin
• ECG repeated
– 2-3 mm ST depression in inferior leads (prior ECG
on review showed ~1 mm ST depression in inferior
leads)
– Cardiology consulted
– Patient taken to cath lab – 95% stenosis of mid RCA
prior to a large RV marginal branch successfully
stented

34. Lessons
• Ischemia can manifest as abdominal discomfort,
classically inferior (RCA) ischemia.
• Ischemia can cause hypotension and bradycardia.
• RV ischemia can be profound and refractory to initial
fluid resuscitation.
• Be wary for post-operative ischemia, especially in
patients at high CV risk (even if “cleared” for surgery).

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