Recurrent Abdominal & Back Pain in a Dialysis Patient
Push-Pull EM Case of the Week for Thursday, August 6, 2009
Case Introduction
It’s a Thursday evening in POD 3. You are getting your butt handed to you and are desperately scanning the patient list for an “easy one” to knock off in a feeble push to clean up your POD. A 48 yo male presents to the ED with a listed chief complaint of Chronic Renal Failure. Your mind instantly goes into autopilot with dreams of a “quick one.”
You turn to your POD lead and ask if they’ve ordered the usual. She informs you that this patient already had dialysis today and was here for something else. She continues to clarify that he was once a “compassionate dialysis “ patient, but had recently become funded and in now getting dialysis at an outside institution. He arrived this evening with complaint of severe abdominal and back pain and appears in significant distress.
Triage Note: … Pt groaning loudly, stating repeatedly "aye! Aye! My back hurts. Aye! Aye!" Pt also seen attempting to gag self by putting finger down throat.
Vitals: T 36.3, P 79, BP 178/95, RR 17, 95% on RA
Concerned by the story, you immediately get up to go see the patient, as you know these folks have multiple opportunities for badness. You walk into the room and see a 48 year old male, appearing older than stated age, actively moaning in pain with both hands grasping his stomach. He appears in substantial distress. The patient explains that the pain started this evening after he got home form dialysis. The pain is constant (with some intermittent exacerbations), sharp and cramping. It involves the bilateral flanks, as well as the entire abdomen. He reports nausea, but denies F, V, D, CP, SOB. The patient informs you he had a similar episode 3 days ago and was seen here Parkland. He implores you for pain control.
PE: NCAT, PERRL, RRR, CTAB, no CVAT; abd is soft with diffuse, moderate discomfort to palpation, no rebound or guarding; neuro intact, no skin changes.
You go back to the computer to review the patient’s previous visit. The notes portray a very similar picture of severe pain. He presented with severe left-sided back and abdominal cramping, describing the episode as more severe than anything felt in the past. The pain had been persistent for three days, but was worse that day specifically after dialysis. You are surprised to see that all the patient’s labs from that visit were normal. You are even more floored to see that the patient received a CT of the chest, abdomen and pelvis “The Trifecta” that visit. Imaging studies were remarkable for several non-specific findings, but nothing to explain the pain. The patient’s pain improved with medication and he was discharged with a diagnosis of lumbosacral pain. The decision-making was not documented.
As your POD continues to blow up, you are now stuck to contemplate this interesting (perhaps mildly frustrating) situation…
- What are the possible etiologies of the patient’s pain?
- What workup do you want to do?
Case Conclusion
This case is a bit of a challenge. You have a patient with a substantial number of comorbidities who exhibits signs of severe pain, but your exam is not proportional and you have a very extensive workup on file from 3 days earlier that yields no remarkable abnormalities. A quick literature search reveals that a common etiology of abdominal pain and flank pain in dialysis patients can be renal stones. Additionally, further reading reveals that some cramping may occur post dialysis due to electrolyte changes and abnormalities. You discuss the case and your research with your attending and decide on a workup of labs (including lactate) and a renal colic CT. Meanwhile, your patient seems to be much more content after pain control with IV Morphine. As you wait for the labs and CT, you decide to review more in the patient’s chart.
Nursing notes from the previous visit read as follows:
- 2100 - Pt arrived via EMS from dialysis center c/o severe back pain and LUQ pain x3 days. Pt is moaning and appears very uncomfortable. Per EMS, pt was very hypertensive during transport.
- 0030 - After administration of pain medications, pt is now lying supine in bed without facial grimacing noted. Pt awaiting further MD dispo.
- 0200 - Pt requesting more pain meds at this time. MD notified.
Nursing notes from the current visit read as follows:
- 2200 - Pt arrived stating "I want iv morphine." Pt groaning loudly, stating repeatedly "aye! Aye! My back hurts. Aye! Aye!" Pt also seen attempting to gag self by putting finger down throat.
- 2300 - Pt continues to put finger down throat and violently spit and hork in emesis bag. No vomiting at this time, despite pt's numerous attempts to do so.
- 0000 – Morphine given
- 0200 - Pt to nurses station asking for pain medication.
- 0300 – Morphine given
You bomb off to see a few more patients, intermittently checking for return of your labs and CT read. Once they are back you are surprised (or not so surprised) to see that everything is again unremarkable for the patient. In a last ditch effort to gain insight into the situation, you call the renal fellow to see if there is any phenomenon known that could be causing the patient’s pain. He notes that volume contraction and electrolytes shifts may precipitate these symptoms, but otherwise can’t explain the pain and has no suggestions for further workup. Pain medicine dependence is mentioned as a concern. His recommendation is to notify the patient of our findings and have him follow up with his doctor. On reevaluation, the patient’s pain had resolved. He was informed of the lab and CT findings and concerns were expressed about pain medication dependence. He was discharged with a diagnosis of generalized body pain.
Now 3 days later…
Curious about the outcome of this patient, you decide to take a peek at his chart to see if he had any repeat visits. He indeed returned just 3 days later.
Triage note: Pt here with abd pain. Reports in hospital a wk ago for same thing. Hx of high bp, diabetes, and CKD. Pt with periodic vomiting . Moaning in pain.
MD Plan documented as order abdominal labs and provide pain control. The patient received both IV and PO narcotics. His pain resolved and he was discharged with a diagnosis of unspecified abdominal pain.
Topics to think about:
- How should this case be managed in light of this apparent pattern?
- Are we managing pain in our dialysis patient’s appropriately?