Mid-epigastric Pain and Emesis in a 95-Year-Old Woman

Symptoms have been present for 2 days. Lab studies are notable for BUN (43 mg/dL) and CO2 (21 mmol/L). The real problem is visible on CT of the abdomen and pelvis. Your diagnosis?

A 95-year-old woman with GERD, hypertension, hypothyroidism, and a history of aortic valve surgery and warfarin therapy, and remote cholecystectomy presents to the emergency department with mid-epigastric pain and non-bloody, non-bilious emesis of 2 days’ duration. She states that the pain is constant and not affected by activity but does seem worse after meals. She denies any fever, chest pain, or trouble breathing. She denies recent antibiotics, recent travel, or any known ill contacts.

Her vital signs are normal except for slight tachycardia, which improved with fluids. HEENT: Eyes clear. Oropharynx is moist. LUNGS: Clear. No wheezes or rales. HEART: Regular rate and rhythm. ABDOMEN: Soft with mild diffuse tenderness. No rebound, guarding, or rigidity. EXTREMITIES: Trace edema. Laboratory investigation reveals the following: INR 1.7. Metabolic panel is normal except for BUN level of 43 mg/dL and carbon dioxide of 21 mmol/L. Hepatic function and lipase levels are normal. CBC count shows a white cell count of 19.6 x 109/L, but no bands. Urinalysis results are normal and results of a cardiac troponin test are negative.

Figures at right show cuts from her CT scan of the abdomen and pelvis.

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