Lung pathologies associated with abdominal pain

Patients with diffuse upper abdominal pain can have pulmonary pathology, particularly when the patient also has pulmonary symptoms like cough or shortness of breath. Uptodate recommends that in patients with diffuse upper abdominal pain and associated pulmonary symptoms, chest imaging should be done. For example, patients with suspected pneumonia should have chest radiography, while patients with suspected pulmonary embolism should have a chest CT scan.

Now I’m going to talk a little more about how pneumonia and pulmonary embolism can present with abdominal pain….

Pneumonia

Pneumonia can present with GI symptoms which include vomiting, diarrhea, weight loss, anorexia, and abdominal pain. The abdominal pain comes from pleuritic irritation caused by a basilar infiltrate. The pain is generally sharp and aggravated by cough or deep inspiration. Pneumonia caused by Legionella( mostly community acquired pneumonia) is clinically and radiographically similar to other forms of pneumonia. Symptoms( fever, cough, SOB) arise 2 to 10 days after exposure to contaminated water or soil. No clinical features reliably distinguish Legionnaire’s disease presents with certain features such as abdominal pain, nausea, vomiting and diarrhea which raise the index of suspicion for it and distinguishes the disease from other types of pneumonia,.

TX: macrolides( azithromycin, clarithromycin) or respiratory fluoroquinolones( Levaquin)

Pulmonary embolus (PE)

PE can present with nonspecific symptoms which may include upper abdominal pain. Two possible mechanisms for abdominal pain are pleural irritation of the diaphragm causing an ileus ( free air under the diaphragm) and hepatic congestion from acute right ventricular failure. Up-to-Date did mention that it seems unlikely that abdominal pain would be the only manifestation of PE

I did find a case of massive pulmonary embolism presenting as an acute surgical abdomen that underwent exploratory laparotomy.

Case:

A 35-year-old healthy, nonsmoker female school teacher previously on an oral contraceptive pill x 2 years presented to the emergency department after collapsing at her workplace with severe epigastric pain, periumbilical pain, and gross abdominal distension x 1 hour duration. She denied dyspnea or chest pain. On examination she was in extreme pain and bending her knees.

Her vital signs

BP 154/67, pulse rate 123, O₂Sat 98% on room air, respiratory rate 27 per minute, and temperature of 34.3°C(low).

Physical examination: chest was unremarkable, but abdominal exam revealed a tender distended abdomen with hepatomegaly.

Electrocardiogram: sinus tachycardia 123 per minute with no evidence of S1Q3T3.

Abdominal ultrasound: free fluid in the upper abdomen and around the inferior border of both liver and spleen.

Routine laboratory testing on arrival in the emergency department revealed the following results: hemoglobin (Hb) 11.7 g/dL, white cell count 11 × 10⁹/L,

ABG showed severe metabolic lactic acidosis, pH 6.68, PaO₂ 24 kPa, PaCO₂ 5.49 kPa, HCO₃ 6.9 mmol/L, BE negative 27, and a lactate of 12.4 mmol/L.

So what end up happening,

The patient developed cardiac arrest 90 minutes after presentation to the emergency department and received 2 minutes of cardiopulmonary resuscitation with chest compressions, The patient was intubated and transferred to the intensive care unit. In the intensive care unit, the patient’s extremities were cool to touch with nonpalpable peripheral pulses.

After surgical evaluation in the intensive care unit, the patient was emergently taken for an exploratory laparotomy because her Hb dropped to 6.6 g/d in repeat testing and her distended abdomen on exam.

The D-dimer( elevated) returned while the patient was in the operating room and was 21.11 µg/mL (normal range <0.4).

Computed tomography (CT) chest showed large thrombus in the right pulmonary artery and a thrombus in the two third order branches of the left lower lobe pulmonary artery.

Tx: Following discussion with cardiologist and interventional radiologist, it was decided not to proceed with embolectomy, and heparin infusion was commenced, which was converted to therapeutic low-molecular-weight heparin the following day

Conclusion: Emergency department physicians should be aware that massive pulmonary embolism could present as an acute surgical abdomen in young healthy individuals. Cause: oral contraceptive

My Thoughts:

I thought this case was important to share because abdominal pain is not often associated with pneumonia, but it is a common chief complaint in the emergency department. It just made me think that in medicine, the patient may not always “read the textbook” and present with the most common symptom so it’s important to do a thorough physical exam and sometimes consider other differential diagnosis.

 

Source:

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/causes-of-abdominal-pain-in-adults?search=abdominal%20pain%20and%20pulmonary&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H7

https://www-uptodate-com.york.ezproxy.cuny.edu/contents/clinical-manifestations-and-diagnosis-of-legionella-infection?sectionName=Clinical%20features&search=abdominal%20pain%20and%20pulmonary&topicRef=6860&anchor=H2882433715&source=see_link#H2882433715

https://accessmedicine-mhmedical-com.york.ezproxy.cuny.edu/content.aspx?bookid=2683&sectionid=225058097

Al-Mane N, Al-Mane F, Abdalla Z, McDonnell J. Acute Surgical Abdomen: An Unusual Presentation of Pulmonary Embolus. J Investig Med High Impact Case Rep. 2014;2(3):2324709614542339. Published 2014 Jul 27. doi:10.1177/2324709614542339

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4528903/

https://www.aafp.org/afp/2006/1101/p1537.html