A 35‐year‐old man was admitted with right upper quadrant pain, nausea, vomiting, and obstipation. He had had 9 presentations with 4 admissions for the same in the preceding 3 months. Recent history included numerous admissions to other local facilities with similar symptoms, resulting in extensive workups including exploratory laparotomy. History included chronic pancreatitis since childhood with an unspecified “drainage” procedure at 15 years. The patient was unaware of other childhood medical history. He was diagnosed with diabetes at age 33 and frequently presented with marked hyperglycemia (up to 1154) with normal AG, had a HgA1c of 10.0 and bilateral Charcot ankles and feet. He was hepatitis C positive but HIV negative. Social history included homelessness with stays at shelters/treatment programs. He smoked cigarettes, had prior methamphetamine and heroin use, and denied alcohol abuse. He did not know his father and was estranged from other family. Exam revealed a thin white man, mildly uncomfortable from belly pain. Cardiopulmonary exam was benign, but he had diffuse tenderness on abdominal palpation with a softly protuberant belly and no hepatosplenomegaly or ascites. There was mild digital clubbing and skeletal muscle atrophy. Labs revealed transaminitis (163/246) with bilirubin of 0.4, INR of 1.2, lipase < 3, and triglycerides of 43. Toxicology screen was negative. No gallstones were present on ultrasound, liver was normal by CT scan, but the pancreas was atrophic and calcified. There were perigastric, perisplenic, and upper abdominal varices without ascites. Moderate to large amounts of stool were present. Esophagogastroduodenoscopy showed a large food bezoar in the stomach. Visceral arterial/venous scan showed patency and normal flow in evaluated vessels. Chest x‐ray was normal. A CFTR screen was sent because of physical exam findings, presence of pancreatitis, diabetes, and other gastrointestinal abnormalities. The patient was heterozygous for deltaF508 and had diagnostic sweat chloride tests of 75 and 77.
Cystic fibrosis (CF) is most commonly diagnosed in childhood, but 4% are diagnosed as adults. Late diagnosis is associated with milder disease, but here was likely also driven by poor family support and health care access. Importantly, CF does not equate with respiratory disease. Heterozygotes typically have a less common second mutation and often present with atypical disease. A positive sweat test is diagnostic and obviates the need for further genetic testing. Treatment is largely supportive, but routine follow‐up at a CF center is recommended.
Acute symptoms were easily explained by presenting abnormalities—hepatitis C, diabetes, gastroparesis, chronic pancreatitisall confounded by noncompliance and substance abuse. As hospitalists, however, it is imperative for the welfare of our patients and the health care system that we look beyond the proximate causes for the presence of a unifying diagnosis so we may care appropriately for our patients.
C. K. Wallace ‐ none
To cite this abstract:Wallace C. Abdominal Pain in an Adult—considering the Totality. Abstract published at Hospital Medicine 2011, May 10-13, Dallas, Texas. Abstract 425. Journal of Hospital Medicine. 2011; 6 (suppl 2). https://www.shmabstracts.com/abstract/abdominal-pain-in-an-adultconsidering-the-totality/. Accessed July 23, 2019.