Replay to Jennifer
The patient in question is a 64-year-old African American male who presents with epigastric pain that began two days ago and continues to increase. He has a high stress job as a stock broker and was recently served divorce papers. He admits to recent increased alcohol intake in order to manage stressors and currently smokes one and a half packs of cigarettes daily. Findings upon physical examination include a blood pressure of 140/88, a heart rate of 110 bpm, and abdominal pain rated 8/10. Pain is self-described as steady, sharp through to his back, with a constant burning sensation. Examination of lungs and heart are unremarkable. He does have epigastric and liver tenderness upon palpation. No nystagmus, tremor, or asterixis which would be indicative of withdrawal from alcohol.
What are the possible causes of his abdominal pain?
Gastritis – Inflammation of the stomach lining as seen in gastritis is often caused by H. pylori. Without a self-reported history of H. pylori treatment, the cause of gastritis may be related to tobacco smoking, alcohol consumption, and/or the use of non-steroidal anti-inflammatory drugs (NSAIDs) or steroids (Azer & Akhondi, 2022).
Peptic Ulcer – Peptic ulcer disease (PUD) most commonly presents with epigastric pain that may be associated with dyspepsia, bloating, abdominal fullness, nausea, and early satiety (Kavitt et al., 2019). The clinician should obtain a clear history of any prior NSAID use and if the patient has had any documented H. pylori infection (Kavitt et al., 2019). An upper endoscopy would be useful in accurately diagnosing this condition.
Acute Pancreatitis – Acute pancreatitis frequently presents with epigastric pain, jaundice, and hyperlipidemia. It can be seen in the setting of alcohol abuse, and liver or gallbladder disease (Goolsby & Grubbs, 2019).
GERD – The hallmark symptoms of GERD are heartburn and acid regurgitation; however, patients may also present with chest pain (Maret-Ouda et al., 2020). With regular alcohol consumption, the esophagus may become eroded and lose the lower esophageal sphincter may lose its efficiency in closing. An increased frequency of alcohol intake is directly correlated with the development of GERD (Pan et al., 2019).
Abdominal Aortic Aneurysm – An abdominal aortic aneurysm is a life threatening condition that is most commonly caused by arteriosclerosis. Other risk factors include history of smoking, advanced age, family history, hypertension, and hypercholesterolemia (Goolsby & Grubbs, 2019). Prominent lateral abdominal pulsations are suggestive of an AAA (Goolsby & Grubbs, 2019).
What further questions would be pertinent in light of the patient’s pattern of drinking?
· Have you ever had a drinking problem?
· When was your last drink?
· Do you feel you have a drinking problem now?
· Are you at all concerned about your drinking?
There are many screening tools to identify alcohol misuse including CAGE, AUDIT/AUDIT-C, CRAFFT, T-ACE, TWEAK, and NIAAA (Pan et al., 2019). The use of questionnaires to assess alcohol use disorders and to identify those who excessively drink may be helpful not only in arriving at an accurate diagnosis, but also to help prevent future health problems.
What are the areas of the physical exam that are important to this patient?
· Vital signs: BP 140/88, 110 bpm, 100.8 F. Alcohol can suppress the body’s control over maintaining a normal core temperature. An elevated temperature and heartrate may indicate withdrawal.
· Lung and cardiovascular exam – Unremarkable findings upon palpation and auscultation
· Abdominal exam – Particular focus to the right upper quadrant would be important. Assess for rebound tenderness, general tenderness, masses, and pulsations (Goolsby & Grubbs, 2019). Auscultate for bowel sounds and possible abdominal bruits.
· Neurological exam – Perform a neurologic exam to assess for any symptoms of alcohol withdrawal. Observe for symptoms such as nystagmus, tremor, and asterixis.
Diagnostic Considerations in Order of Importance with Rationale
· Alcoholic Gastritis – The patient admits to recent excessive drinking. Alcohol can slowly erode the lining of the stomach which may cause a person to assume they only have heartburn or indigestion. If erosion is significant, it may cause GI bleeding. Patient’s heart rate and temperature are slightly elevated which can be indicative of alcohol withdrawal. Alcoholic gastritis is the patient’s likely diagnosis which is likely being spurred on by recent stressors.
· Peptic Ulcer – The most common causes of peptic ulcers are H. Pylori infections and chronic use of NSAIDs. The patient does have radiating pain and complains of a constant burning sensation in his stomach, however there are no signs of bleeding. A thorough review of the patient’s medications is warranted to rule out a history of chronic NSAID use.
· Acute Pancreatitis – Although the patient has abdominal pain that radiates to his back, he doesn’t mention increased postprandial pain, weight loss, or steatorrhea. Pain with pancreatitis can be severe and debilitating.
· GERD – Having a history of alcohol use may cause loss of tone in the lower esophageal sphincter, thus permitting stomach contents and acid to back up into the esophagus. The patient does not mention any sensation of heartburn, dysphagia, or reflux so this is not a likely diagnosis.
· Angina – Epigastric pain and tenderness in the setting of hypertension and a significant smoking habit warrant further diagnostics including an initial EKG to assess for CAD.
The next 5 Steps:
· Labs: Order a CBC with differential to assess for anemia possibly related to an internal bleed or sign of infection. Check CMP to evaluate electrolytes and liver function (AST and ALT) – ALT is more specific to alcohol induced liver injury (Peterson, 2004). Check Gamma-Glutamyltransferase (GGT) since elevated GGT can be indicative of early liver disease (Peterson, 2004); Order Amylase and Lipase levels to check for indications of pancreatitis. Finally, perform a blood and urine toxicology screen to rule out substance abuse.
· Esophageal-gastric endoscopy – An upper endoscopy is useful in accurately diagnosing peptic ulcer disease and identifying damage caused by GERD. It would be particularly important in those who are greater than 60 years of age, have a family history upper GI malignancy, have had recent weight loss, early satiety, dysphagia, GI bleed, iron deficiency anemia, or vomiting (Kavitt et al., 2019). An endoscopy may also be able to give insight as to whether or not an ulcer is malignant.
· Abdominal Ultrasound or CT scan – These tests can help identify hepatomegaly, unusual masses, or risk for aortic aneurysm. An abdominal CT can also rule out acute cholecystitis, cholelithiasis, abscesses, or bile duct blockage.
· Electrocardiogram – An EKG can rule out any cardiac underpinnings that might be associated with the patient’s chest pain. Often upper GI complications manifest as suspect cardiac issues.
· Refer to therapist – Offer cognitive behavioral therapy to address patient’s current habits and to provide the tools and awareness to make life enhancing choices and better manage stress.