VOMITING

62yo female presented with vomiting for 4/7 and decreased appetite. 

She was moderately dehydrated with dry mucous membranes, HR 110 SR and BP 145/80. She was initially aferbile and then spiked a fever to 38 while in the department.. 

Further Hx revealed intermittent LIF pain and constipation. She also stated she felt she had incomplete bladder emptying. But the prominent feature of the hx was vomiting. 

Nil previous abdominal surgery or pathology.

On examination, LIF tenderness without guarding, nil herniae.

Relevant pathology: urine clear. WCC 13 with neutrophilia. CRP 90.

As you can see for this patient, the DDx is wide.

This is a video of her LIF:

Given the bowel looks normal with no evidence of obstruction or abscess formation, you would go on to look for other causes of abdominal pain. 

Images of her aorta:

normal calibre aorta, nil dissection flap

Images of her renal system are below:

Left: Left kidney long. Right: bladder trans

So this patient had an infected obstructed L kidney. She went on to have a left JJ stent and had an uneventful recovery. 

My initial impression from her story and examination was L diverticulitis, abscess formation and maybe associated ileus causing vomitting. She was given ceftriaxone and metronidazole while awaiting CT. 

CT revealed the obstructed L kidney.  US at the bedside would have changed her management and admitting unit. It was sad to go back and get those images of an easily visualised L obstructed kidney after the CT diagnosis!

For a detailed discussion of HYDRONEPHROSIS click on the button below:

APPROACH TO POCUS IN VOMITTING AND ABDOMINAL PAIN

Given I am sometimes too focussed with my POCUS question and have missed pathology because I am not looking for it, in undifferentiated abdo pain/ vomitting, I tend do a quick systematic US examination of the abdomen now. 

Like an EFAST for abdo pain, this consists of looking at all the things that could cause pain and vomitting in that region until I find pathology:

1. In generalised abdo pain/ vomitting:

         a. dilated loops of bowel with washing-machining (SBO)/ faecalised contents

         b. abnormal looking bowel with thickened walls and hyperechoic fat (appendicitis RIF                      and diverticulitis in LIF)

         c. Aorta: dilated/ dissection flap

         d. Bladder: distension/ stone at VUJ

         e. kidneys: hydronephrosis/ perinephric FF

          f. heart: pericardial effusion/ DCM

  2. In RUQ/ epigastric pain

         a. GB: stones/ sludge/thickened wall

         b. Liver: mets/ intrahepatic duct dilatation

         c. pancreas: head/tail mass, dilated pancreatic duct

         d. Aorta: dilated/ dissection flap

         e. lung: effusion/ B lines/ consolidation

         f. kidney: hydronephrosis/ perinephric FF

         g. heart: DCM/ pericardial effusion

3. LUQ 

        a. spleen: enlargement/ dilated vessels

        b. kidney: hydroneprhosis/ perinephric FF

SBO Images

APPENDICITIS