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Acute Abdominal Pain in a Patient on High Dose Steroids


Case Study

A rapid response event was activated for a patient for acute onset abdominal pain and hypotension. On arrival of rapid response (RRT) personnel, the patient was a 65-year-old male with a known history of chronic obstructive pulmonary disease (COPD), active smoking, and chronic back pain for which he was taking ibuprofen daily. The patient was admitted two days before for a COPD exacerbation and was receiving prednisone 60 mg daily. He had received a dose of 125 mg of IV methylprednisolone at the time of admission.

Vital Signs

  • Temperature: 98 °F, axillary

  • Blood Pressure: 80/55 mmHg

  • Heart Rate: 135 beats per min (bpm)

  • Respiratory Rate: 25 breaths per min

  • Pulse Oximetry: 97% on 2 L nasal cannula

Focused Physical Examination

A quick exam showed a severely distressed man who appeared tachypneic and was attempting to lay in bed motionless. His abdominal exam showed diffuse guarding and rigidity. Significant tenderness was noted on palpation of all quadrants. Bowel sounds were hyperactive. Lungs had mild expiratory wheezing. His cardiac exam was unremarkable.

Interventions

A cardiac monitor and pads were attached immediately. A 16-G intravenous (IV) access was established, and a 1 L IV fluid bolus was started. In addition, 1 mg IV hydromorphone was administered for pain. A stat lactate level, troponin level, complete metabolic panel, complete blood count (CBC), and lipase level were ordered. Electrocardiogram (EKG) was obtained, which showed sinus tachycardia; no acute ST changes were seen. An upright abdominal X-ray was ordered but could not be completed given the patient’s severe distress. Blood pressure showed improvement with the fluid bolus, and emergent computed tomography (CT) scan of the abdomen was obtained ( Fig. 53.1 ). Findings were consistent with acute duodenal perforation. Based on the patient’s clinical history, a perforated duodenal ulcer seemed like the most probable cause. The patient was immediately given a dose of IV pantoprazole, and a stat consult was placed for surgery. The patient was transferred to the intensive care unit for further management and treatment planning.

Fig. 53.1, CT abdomen without contrast showing free air in the abdomen (pneumoperitoneum)

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