Tied up in a knot with a twist at the end!

Author: Bethany Davies, Fui Xuan Pong, Riad Hosein / Editor: Steve Corry-Bass / Codes: Published: 30/03/2021

A 47-year-old lady presents to the Emergency Department with acute epigastric pain radiating to the back.

It is of sudden onset, started a few hours ago, is stabbing in nature, and non-radiating. She denies any vomiting but reports minor abdominal distension. She has experienced this pain previously, but not this intense, describing it as 10/10 severity. Nevertheless, she is able to pass flatus and opens her bowel normally. Her past medical history includes gastritis, hysterectomy and previous small bowel obstruction (SBO) due to adhesions (managed conservatively). Her alcohol consumption averages 13 units per week. On examination, her abdomen is soft, but exquisitely tender in the epigastric region with no guarding, rebound tenderness or rigidity. Bowel sounds are present and normal.

Observations are as follows: temperature 36.5 degrees, BP 150/90, HR 55, RR 15, oxygen saturations 98% on room air. Venous blood gas shows a lactate of 4.8 but with a normal pH, base excess and bicarbonate. Intravenous (IV) fluids and analgesia are given. Due to the nature and severity of the pain, the patient is reviewed by surgical team.

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