Abdominal pain is a frequent complaint for patients who come into the emergency department.
It can have many possible causes and range from relatively harmless to life threatening. Depending on a patient’s age and past medical history, I formulate a list of potential diagnoses at our first meeting. I add to or subtract from that list when I examine the patient and order lab and imaging tests. Often the tests confirm my initial thoughts and sometimes the diagnosis is surprising or unexpected.
Todd came to the emergency department (ED) with abdominal pain, nausea, vomiting and diarrhea. He looked uncomfortable when I went in to see him. He was in his early 40s and had been seen in the ED previously for similar symptoms, most recently about six weeks earlier when he was diagnosed with diverticulitis.
Diverticulitis is inflammation or infection of diverticula — small, bulging pouches of the intestinal tract. These diverticula are common and do not cause a problem unless infected or inflamed. Diverticulitis is generally treated with antibiotics; however, severe cases may require hospitalization or even surgery. Todd was discharged home on antibiotics from his last ED visit.
Todd finished his antibiotics and several weeks later his symptoms started again. He felt bloated after eating and had cramping in his lower abdomen. When he came to the ED, he had more severe pain in the left lower quadrant of his abdomen and was nauseous. He had a slight fever and his heart rate was elevated. I ordered IV fluids, medications for pain and nausea, as well as lab tests and a CT scan of his abdomen. I was worried he might have developed an abscess or a perforation of his intestine.
Todd’s lab work showed an elevated white blood cell count, which fit with infection in his abdomen. A short time later, the radiologist told me that Todd did have a lot of inflammation in his colon. However, the radiologist was concerned by a possible mass around the area of inflammation that needed to be further evaluated based on his earlier CT scan.
Todd asked for more pain medications, and I gave him antibiotics to treat his diverticulitis. I sat down with him and reviewed the radiologist’s report and asked Todd if there was any family history of bowel problems or colon cancer and he said there was not. He was understandably worried by the possibility of a mass in his colon and I talked to him about being admitted to the hospital.
Todd was later seen by our surgeon and underwent a biopsy.
Colon cancer is diagnosed in about 150,000 patients annually in the United States. The lifetime risk of developing colon cancer is approximately 6%, but people with a family history of colon cancer have a higher risk. It usually begins as a precancerous polyp or abnormal growth in the colon or rectum. It is recommended that high risk patients undergo screening exams before turning 50 and other adults at age 50.
Screening tests can include stool tests checking for blood or abnormal DNA that can indicate a problem. Additional screening tests are sigmoidoscopy or colonoscopy where a physician uses a scope to look at the colon from the inside. A sigmoidoscopy checks the rectum and end portion of the colon, whereas a colonoscopy checks the rectum and the entire colon. During these procedures the physician is looking for polyps or masses that can be biopsied and removed.
Unfortunately, Todd’s biopsies were positive for colon cancer. He underwent surgery a few days later to remove the end portion of his colon. He had to have a colostomy with the surgeon planning to reattach the colon to his rectum after several months. He had an appointment to see the oncologist a week after he got out of the hospital where they would determine what additional treatment (such as radiation or chemotherapy) Todd would need for his cancer. During his surgery the surgeon biopsied several lymph nodes near where the colon mass had been and those came back negative for cancer, making us hopeful that the cancer had not spread beyond his colon.
Finding cancer on a patient in the emergency department is hard. Whether the cancer is related to their presenting symptom, or something found incidentally, it is not what they expect to hear when they come to the ED. I’m glad the radiologist scrutinized the CT scan and found the mass and that we were able to get Todd diagnosed quickly. I am also hopeful that Todd will be able to live a healthy life after this minor setback.
Dr. Erika Kube is an emergency physician who works for Mid-Ohio Emergency Services and OhioHealth.