Method
CASE DESCRIPTION
A 21-year-old medical student presented to the emergency room with severe colicky abdominal pain at right hypochondrium two hours after dinner. The patient gave history of an episode of diarrhea before the onset of pain abdomen. There was no history of melena or hematemesis. He also had nausea and two episodes of vomiting following the diarrhea. Then, the abdominal pain started shortly afterwards which was intermittently severe and non-migratory. He took no medication and had no allergies. There was no family history of bleeding diathesis.
On presentation, he was drowsy and afebrile with blood pressure of 110/65 mm Hg and pulse of 98 beats/min. On examination, the abdomen was soft but had a right-sided fullness and tenderness. Based on the presentation and similar history of food poisoning two months ago, acute gastroenteritis (AGE) was suspected. The patient received IV antibiotics, analgesics and fluid resuscitation. Initial blood report showed a hemoglobin (Hb) of 11.2 g/dL, white blood cells of 14×109/L, with normal platelet count and amylase level. On Arterial Blood Gas (ABG) analysis the lactate was 2.0 mmol/L, the pH was 7.30. Fluid resuscitation continued with 2000 ml of fluids in the first 3 hours.
The next morning, the patient still complained of colicky abdominal pain. His hemoglobin had dropped to 10.8 g/dL in the morning. Contrast Enhanced Computed Tomography (CECT) revealed a large mesenteric hematoma in the right iliac fossa measuring approximately 8.2 × 6.2 × 8.7 cm. The hematoma had a central hyperdense focus probably due to an injured branch of Ileocolic artery (Figure 1). On subsequent questioning, the patient recalled a blow to the right hypochondrium while playing basketball two days back. During the game, our patient had jumped and his abdomen landed on the opponent’s shoulder which was being driven forward and up. He, however, mentioned that the pain from the impact was transient and continued playing afterwards. Hence, he did not recall the incident at the day of admission.
Patient was admitted in the Intensive Care Unit (ICU). Further selective visceral angiography of the coeliac trunk/superior mesenteric artery was done which showed no source of bleeding and therefore no embolization was required. The patient was treated with conservative management -intravenous fluids, analgesics, anti-emetics and Tranexamic acid injection. The patient’s hemoglobin level showed improvement to 12.0 g/dL and 14.5 g/dL during the fourth and fifth day after trauma, respectively. Ultrasonography (USG) showed a decreased size of the hematoma on the fifth day after trauma. Once the patient’s condition improved, he was sent home with Omeprazole (dosage: 40 mg once daily) and Ferrous sulphate tablets (dosage: 200 mg thrice daily). The patient was counseled to restrict strenuous physical activities for at least two months.
He was called for follow-up two, four and twelve weeks after discharge in the surgical outpatient department. The mesenteric hematoma showed a progressively smaller size on follow-up USG. It resolved spontaneously and was undetectable via USG by the 12-week follow-up period.