The Case Files

Welcome to the Case Files!
The Case Files is an anecdotal collection of emergency medicine cases to enable physicians and researchers to find clinically important information on unusual conditions.

Case reports should focus on:

  • Unusual side effects or adverse interactions.
  • Unusual presentations of a disease.
  • Presentations of new and emerging diseases, including new street drugs.
  • Findings that shed new light on a disease or an adverse effect.

Comment on a case or submit your own case following the instructions in the Submissions box to the right.

Wednesday, May 10, 2017

A Simple Case of Abdominal Pain in the ED?

​A previously healthy 17-year-old girl presented to the ED with one month of intermittent, burning epigastric pain associated with nausea and vomiting. Pain was worsened by spicy, greasy foods, and alleviated by sparkling water. She said she came to the ED because the pain had persisted for a while and was interfering with her life. The patient denied fevers, recent travel, or a change in bowel movements. She admitted to traveling to Nicaragua many times in her life and to an unintentional 20-pound weight gain over the past year.​

Vitals at presentation were a heart rate of 83 bpm, temperature of 36.6°C, blood pressure of 114/62 mm Hg, and respiratory rate of 20 bpm. Physical exam was significant only for a slightly enlarged nontender thyroid gland and mild epigastric and right upper quadrant tenderness to palpation. The RUQ tenderness on exam prompted a bedside ultrasound to explore for cholelithiasis, choledocolithiasis, cholecystitis, and hepatitis. It showed a gallbladder with a Phrygian cap that appeared normal and a white hyperechoic lesion in the liver that prompted an abdominal ultrasound by an ultrasound tech and a reading by a radiologist.

The patient received one dose of antacids for her abdominal pain, which she said resolved her symptoms. The ultrasound revealed a normal gallbladder and a liver mass characterized as an ill-marginated 3.5 x 5.3 cm echogenic focus in the left lobe of the liver with peripheral hypoechogenicity with internal central vascularity shown by color Doppler. (Shown.) The radiologist recommended an MRI with liver mass protocol to evaluate the lesion. Labs sent by the ED were unremarkable, including a normal coagulation profile, CBC, and CMP.

The patient was admitted for further workup of the unspecified liver mass, for which the differential diagnosis included hemangioma, adenoma (though the patient was not on oral contraceptives), hepatocellular carcinoma, hydatid cyst, and focal nodular hyperplasia. Fortunately for her, the MRI showed focal nodular hyperplasia (FNH). (Shown.) She was seen by the pediatric gastroenterology team, and was discharged with follow-up to monitor the FNH.

FNH is the second most common liver tumor. (Cancer 1980;46[2]:372.) It is believed to occur as a response by hepatocytes to underlying congenital AV malformation. Women with FNH are at risk of developing hemorrhagic foci within the liver when on oral contraceptives. FNH is generally benign other than that increased risk. (Mod Pathol 1989;2[5]:456.) It is important to characterize a liver lesion as FNH to save a patient from unnecessary liver biopsy. The patient had a benign liver lesion, but this case still highlights the important role bedside ultrasound can play in the evaluation, workup, and management of common symptoms presenting to the ED.

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Dr. Gilbert is a first-year emergency medicine resident in the Jackson Health System at the University of Miami. Dr. Supino is an associate emergency medicine residency program director at Jackson Memorial Hospital.