My belly HURTS!

LeShan Broniszewski-Burlingham
State University of New York Polytechnic Institute
March 5, 2017
 CS: 50 y F

January 26, 2017

CC: "My belly

hurts.
HPI: 50y F c/o RUQ abdominal pain x 4 weeks
pain started after eating
continuous, non-radiating
worse after eating but not with drinking
Pain 5-10/10
has tried over the counter acetaminophen, ibuprofen, and an old
script of hydrocodone with no relief

ROS:
General: Rates her health
5/10
Skin: Denies itching,
rashes, jaundice, lesions,
masses, or concerning
moles.
Resp: Denies SOB, cough,
fevers, chills, wheezing,
sputum, hemoptysis, PNA,
TB, bronchitis.
Cardiac: Denies chest pain,
chest pressure, dyspnea,
orthopnea, murmurs or
edema.
GI: 3 weeks spontaneous,
continuous RUQ abdominal
pain, non-radiating, worse
with eating but not drinking
liquids; Pain ranges 5-10/10.
Has tried over the counter
acetaminophen, ibuprofen,
and old script for hydrocodone
with no relief of the pain.
Denies loss of appetite,
nausea, vomiting, diarrhea,
constipation, vomiting blood,
blood from rectum, jaundice,
hepatitis, or dyspepsia. Last
BM today.
GU: Denies renal calculi,
dysuria, hematuria, polyuria,
nocturia, urinary
retention/incontinence,
frequent UTIs.
 MEDS:
Allergies: vitamin B complex 1 po
simvastatin; severe myalgias daily
Provigil 200 mg po daily
omeprazole 40 mg po
PHH: daily
PMH: GERD, migraines,
zinc 30 mg po daily
external hemorrhoids, coQ10 100 mg po daily
hyperlipidemia, D5000 units po daily
hypothyroidism, anxiety, vitamin C 100 mg po
depression, constipation, daily
PCOS, endometriosis, OSA, Mg oxide 1000 po daily
PTSD, obesity,
viibryd 20 mg po daily
hydradenitis, tobacco
abuse. triamcinolone acetonide
0.1% cream QID prn
PSH: C-section (2000), Colace 100 mg (2) @ hs
laparotomy to clean up metformin HCL ER 500
endometriosis and mg (4) tabs daily (2 in
adhesions (2012, 2013) a.m., 2 in p.m.)
levoxyl 50 mcg po daily
livalo 2 mg po daily
 PE:
Vitals: 97.6 97 20 144/86 64 278# BMI:47.7 (morbid obesity)

Skin: No rashes or
lesions.
Resp: LSC; no rhonchi,
wheezing or rales.
Cardiac: Normal S1 and
S2. GI: tender RUQ, non-
radiating. BSP. No
masses, rebound,
FH/SH: Non-contributory guarding or
organomegaly.
What do
you
think???
 Differential DX:

Abdominal pain, RUQ

Constipation
Pancreatitis
Portal vein thrombosis
Hepatitis
Gall bladder disease
Liver abscess
Peptic ulcer
Diverticulitis
Cancer
Partial bowel
obstruction
 Dx: abdominal pain, RUQ

CT abdomen and pelvis

with oral and IV contrast
Cbc

Plan: CMP
Lipase
Fe, TIBC, ferritin
Hep A Ab, IgM
HBsAG Screen
Hep B Core Ab, IgM
Hep C virus Ab
ANA
ESR
Plan:
Patient went to the lab on that day
(1/26/17) and also
had CT completed the following day.

The patient is to keep a food diary for a

week to evaluate
what foods or fluids affect the pain.

She will return in 1 week, sooner if needed.

We will call her with the lab and CT results.

 Test Results:

CT: hemangioma of Lipase: nl

liver Fe, TIBC,
CBC: nl Ferritin: nl
CMP: ALT 63 (nl=7- Hepatitis
52 U/L), ALK 78 panel: all (-)
(nl=34-104 U/L),
ANA: (-)
AST 31 (nl=15-39
U/L) ESR: nl
 Rule Out and Why

Constipation: not seen on CT

Pancreatitis: no fluid around or
inflammation seen on CT; lipase is
nl
Hepatitis: hepatitis panel is all
negative
Liver abscess: not seen on CT
Portal vein thrombosis: no Peptic ulcer: ROS denies dyspepsia, hematochezia, dark
leukocytosis and HCT nl on CBC; tarry stools; Hgb and HCT nl; Fe, TIBC and ferritin nl

not seen on CT Diverticulitis: not seen on CT

Cancer: not seen on CT
Partial bowel obstruction: not seen on CT
We are left with: Abdominal pain, RUQ

Now what?
Follow up visit: 2/2/17

CC: "My
belly still
hurts.
HPI: 50y F c/o RUQ abdominal pain x 5 weeks
pain started after eating
continuous, non-radiating
worse after eating but not with drinking
Pain 5-10/10
has tried over the counter acetaminophen, ibuprofen, and an old
script of hydrocodone with no relief
She was reassessed and again DX with
abdominal pain, RUQ

She did not bring her food diary

with her but tells us she found no
correlation between any specific
foods and that all foods cause
increased pain. Liquids still do
not.
What do we do now?
 Plan:
(HIDA)
Hepatobiliary scan
 The HIDA scan was completed 2/3/17.

HIDA was normal with a normal ejection fraction.

The patient was scheduled to return to the office 2/9/17.

This is when I first saw her.
 HPI: 50y F independently
ambulates into the exam room
c/o continued RUQ abdominal
February 9, 2017 pain x 6 weeks. The pain started
after eating, has remained
continuous, non-radiating, worse
CC: after eating any foods but not
with drinking any liquids, and
"My abdomen ranges from 5-10/10. The patient
has tried over the counter
still hurts. I'd acetaminophen, ibuprofen, and an
like to know old script of hydrocodone with no
what is relief of the pain. She was
previously dx with endometriosis
causing this in 7/2016. Patient presented to us
pain." for this pain 2 weeks ago. We sent
her for a CT scan of her abdomen
and pelvis 2 weeks ago which
showed a hemangioma on her
liver. Approximately 1 week later
we sent her for a hepatobiliary
(HIDA) scan which is normal with
a normal ejection fraction.
 ROS:
She again did not bring her food diary with her but
tells us she found no correlation between any specific foods
General: Rates her health cause increased pain. Liquids still do not.
5/10, citing several
abdominal and pelvic
problems with pain.
Skin: Denies itching, rashes,
jaundice, lesions, masses, or
concerning moles.
Resp: Denies SOB, cough,
fevers, chills, wheezing,
sputum, hemoptysis, PNA,
TB, bronchitis. Last CXR
12/2016 (-).
Cardiac: Denies chest pain,
chest pressure, dyspnea,
orthopnea, murmurs or
edema. Last EKG 12/2016:
NSR.
and that all foods
GI: 6 weeks spontaneous, continuous RUQ
abdominal pain, non-radiating, worse with
eating any foods but not with drinking any
liquids; Pain ranges 5-10/10. Has tried over
the counter acetaminophen, ibuprofen, and
old script for hydrocodone with no relief of the
pain. GERD (2009). External hemorrhoids.
Last EGD 2009. Colonoscopy: Refused. Denies
loss of appetite, nausea, vomiting, diarrhea,
constipation, vomiting blood, blood from
rectum, jaundice, hepatitis.
GU: Denies renal calculi, dysuria, hematuria,
polyuria, nocturia, urinary
retention/incontinence, frequent UTIs.
Endometriosis (2012) with 2 surgeries to
remove adhesions and endometriosis (2012,
2013). G1P1; delivered daughter by C-section
(2000). Pregnancy, delivery, and post natal
period uncomplicated. Denies PCOS (2013).
Perimenopausal; LMP 2/11/2016. Last PAP
6/2016 (-).
Allergies: simvastatin; severe myalgias
Medications, Allergies, PMH and PSH are unchanged
PHH:
PMH: GERD, migraines, external
hemorrhoids, hyperlipidemia,
hypothyroidism, anxiety,
depression, constipation, PCOS,
endometriosis, OSA, PTSD,
obesity, hydradenitis, tobacco
abuse.
PSH: C-section (2000),
laparotomy to clean up
endometriosis and adhesions
(2012, 2013)
MEDS:
vitamin B complex 1 po daily
Provigil 200 mg po daily
omeprazole 40 mg po daily
zinc 30 mg po daily
coQ10 100 mg po daily
D5000 units po daily
vitamin C 100 mg po daily
Mg oxide 1000 po daily
viibryd 20 mg po daily
triamcinolone acetonide 0.1% cream
QID prn
Colace 100 mg (2) @ hs
metformin HCL ER 500 mg (4) tabs
daily (2 in a.m., 2 in p.m.)
levoxyl 50 mcg po daily
livalo 2 mg po daily
 FH: SH:
SH: Single, never married; 1
daughter who lives at home:
FH: reviewed and non- alive and well. No pets. Works
contributory as a disability counselor full
time. Wears CPAP for sleep
apnea at least 4h a night.
Smokes 1/2ppd with 20y pk
hx. ETOH use: denies. Illicit
drug use: denies. Caffeine: 1
small coffee daily. Eats regular
balanced meals at regular
times. Walks for exercise
3x/wkly. Seatbelts 100%
time. Wears sunscreen in
summer only. Smoke
detectors in the home.
 PE:
Vitals: 98.9-103-20 138/77 97% ra 64" 280# BMI: 48.24 (morbid obesity)
General: Independently ambulatory
into exam room. Is well nourished,
obese female. Is awake, alert,
oriented to person, place, time,
answers appropriately, follows
commands, makes good eye contact
and smiles. She is neatly groomed
with clean clothes; no odors.
Skin: Fair, warm, dry. Equal hair
distribution, nails trimmed. No rashes,
lesions, masses, or moles.
Resp: LSC; no rhonchi, wheezing or
rales. Normal AP diameter with equal
chest expansion. Respirations easy
and regular.
Cardiac: Normal S1 and S2; no S3,
S4, lifts or murmurs. PMI L 5th
ICSMCL. Apical regular.
GI: Abdomen soft, tender with deep
palpation RUQ, non-distended. Tender
with percussion RUQ; unable to
complete percussion. BSP x4 quads.
Guarding RUQ. No masses, rebound or
organomegaly.
GU: (-) CVA tenderness. Mild bladder
fullness; no tenderness. External vulva
has equal hair distribution; no lesions.
Vaginal walls pink,moist; no bleeding,
lesions, purulent or creamy drainage.
Cervix pink, moist, circular os; no
lesions or discharge. No cervical motion
tenderness. Uterus and ovaries not
palpable. No femoral lymphadenopathy
or tenderness.
ThoughtsDx?
Differential Dx
Nonalcoholic steatohepatitis
Endometriosis
Adhesions
Fitz-Hugh-Curtis Syndrome
RUQ pain
Pain secondary to the hemangioma
 What are we talking about?

Fitz-Hugh-Curtis Syndrome: Fitz-Hugh-Curtis syndrome occurs

when pelvic inflammatory disease causes inflammation of
the capsule covering the liver and the area around it. It causes
pain in the upper right belly.
This syndrome happens when bacteria enter the abdominal cavity
through the fallopian tubes. They then follow the flow of peritoneal fluid
to the right upper belly, where they infect the liver.
(Fitz-Hugh-Curtis Syndrome, 2017)
 What are we talking about?
Nonalcoholic steatohepatitis (NASH): The diagnosis should be
suspected in patients with risk factors such as obesity, type 2 diabetes
mellitus, or dyslipidemia and in patients with unexplained laboratory
abnormalities suggesting liver disease. The most common laboratory
abnormalities are elevations in aminotransferase levels. Unlike in alcoholic
liver disease the ratio of AST/ALT in NASH is usually < 1. Alkaline
phosphatase and gammaglutamyl trans peptidase (GGT) occasionally
increase. Hyperbilirubinemia, prolongation of PT, and hypoalbuminemia are
uncommon. For diagnosis, strong evidence (such as a history corroborated
by friends and relatives) that alcohol intake is not excessive (eg, is < 20
g/day) is needed, and serologic tests should show absence of hepatitis B and
C (ie, hepatitis B surface antigen and hepatitis C virus antibody should be
negative). Liver biopsy reveals damage similar to that seen in alcoholic
hepatitis, usually including large fat droplets (macrovesicular fatty
infiltration). Indications for biopsy include unexplained signs of portal
hypertension (eg, splenomegaly, cytopenia) and unexplained elevations in
aminotransferase levels that persist for > 6 mo in a patient with diabetes,
obesity, or dyslipidemia. Liver imaging tests, including ultrasonography, CT,
and particularly MRI, may identify hepatic steatosis. However, these tests
cannot identify the inflammation typical of NASH and cannot differentiate
NASH from other causes of hepatic steatosis.
(Herrine, 2017)
 Rule Out
Nonalcoholic steatohepatitis:
CMP: ALT 63 (nl=7-52 U/L), ALK 78
(nl=34-104 U/L), AST 31 (nl=15-39
U/L); ; bilirubin and albumin were
nl; MCV was nl; hepatic steatosis not
seen on CT
 Dx and Plan
Patient's symptoms are likely due to
DX: adhesions or new endometriosis.
RUQ pain Patient wishes to see an OBGYN in
Syracuse. Refer her to OBGYN in
Endometriosis Syracuse for further work-up of RUQ
abdominal pain. Once your OBGYN
Adhesions appointment is scheduled we will
Fitz-Hugh-Curtis Syndrome call you with that information and
we will see you within the week
after that.
The remaining differentials are still in play. We collected a gonorrhea and
chlamydia swab during our pelvic exam and are sending it off. If it is
positive, Fitz-Hugh-Curtis Syndrome will be our diagnosis. If it is negative,
endometriosis and/or adhesions will be our diagnosis. This will be
diagnosed through a work-up by an OBGYN who then will probably do an
exploratory laparoscopy. Remember, CS has a history of endometriosis and
several abdominal surgeries in the past. If that is done, and no
endometriosis or adhesions are found, then RUQ pain secondary to the
hemangioma is the remaining diagnosis from exclusion.
 References
Fitz-Hugh-Curtis Syndrome. (2017). Found online
at WebMD. Retrieved from:
http://www.webmd.com/women/tc/fitz-
hugh -curtis-syndrome-topic-overview
Herrine, S. (2017). Found online at Merck Manuals.
Retrieved from:
http://www.merckmanuals.com/professional/hepa
ic-and-biliary-disorders/approach-to-the-patient
-with-liver-disease/nonalcoholic-steatohepatitis
-nash#v12304868
Questions?