An uncommon cause of upper abdominal pain, nausea and vomiting.
Brief clinical history
A 33-year-old Caucasian man, without any previous medical history, presented to our ED by ambulance. He reported to have cramping upper abdominal pain, without radiation, for ten hours. This pain was accompanied by nausea and vomiting. There was no fever. In the previous four days patient had experienced epigastric pain with pyrosis, for which his general practitioner had prescribed a proton pomp inhibitor two days ago. He reported to smoke three joints a day and he does not drink alcohol anymore. A warm shower three times a day gives pain relief, but does not completely eliminate the pain. The patient had no problems with urinating, his urine seems a bit dark. There were no problems or changes in stool.
The patient was painful and was nauseous. His vital signs were, despite his pain, unremarkable and no fever was present. Cardiac and lung examination showed no abnormalities. Abdominal examination showed painful palpation of the epigastric area and upper left quadrant and left sided flank pain. There were no signs of defense musculaire.
ECG was unremarkable.
Laboratory tests showed a haemoglobin level of 9.1 mmol/L (normal range) with normal leukocytes.. Lactate was normal at 1.7 mmol/L. C-reactive protein was elevated 78 mg/L as was lactatedehydrogenase 673 U/L (range
Urine analysis was weak positive for haematuria.
Misleading elements
A warm shower three times a day gives pain relief, but does not completely eliminate e the pain. Complaints of a gastritis with nausea, pyrosis and epigastric pain.
Laboratory tests showed normal lactate, normal leukocytes.
Urine was weak positive for haematuria.
Helpful details
Pain to the upper left quadrant of the abdomen, nausea and vomiting and elevated C-reactive protein.
CT of the abdomen with intravenous contrast showed splenomegaly with perfusion defects in the spleen, indicating splenic infarctions.
Differential diagnosis and actual diagnosis
Differential diagnosis upon presentation includes: Peptic ulcer, Perforated peptic ulcer, Pancreatitis, Cannabinoid hyperemesis syndrome, Diverticulitis, Kidney infarction, Kidney stones, Splenic infarction, (Splenic abscess)
Diagnosis is splenic infarction.
What is de educational and/or clinical relevance of the case?
Splenic infarction is an uncommon cause of abdominal pain, though one not to be forgotten. Emergency Physicians should keep splenic infarctions in their differential diagnosis, even if a patient presents as a possible acute abdomen or shows symptoms of nephrolithiasis. A normal lactate level does not rule out splenic infarction. When the diagnosis is made, search for the underlying cause.
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