Year :
2022
| Month :
May
| Volume :
16
| Issue :
5
| Page :
XD01 - XD03
Full Version
Inexplicable Abdominal Pain in a Patient with Advanced Recurrent Osteogenic Sarcoma: A Case Report
Published: May 1, 2022 | DOI: https://doi.org/10.7860/JCDR/2022/53791.16390
Chaitanya Rangangouda Patil, Prasad K Tanawade, Nilesh A Dhamne, Navnath Dhone, Kiran G Bagul
1. Consultant, Department of Pain and Palliative Care, Kolhapur Cancer Centre, Kolhapur, Maharashtra, India.
2. Consultant, Department of Radiation Oncology, Kolhapur Cancer Centre, Kolhapur, Maharastra, India.
3. Consultant, Department of Medical Oncology, Kolhapur Cancer Centre, Kolhapur, Maharashtra, India.
4. Consultant, Department of Radiology, Kolhapur Cancer Centre, Kolhapur, Maharashtra, India.
5. Consultant, Department of Surgical Oncology, Kolhapur Cancer Centre, Kolhapur, Maharashtra, India.
Correspondence Address :
Dr. Chaitanya Rangangouda Patil,
A/p. R. S. No. 238, Gokul Shirgaon, Karveer, Kolhapur, Maharashtra, India.
E-mail: docterchaitanya@gmail.com
Abstract
Abdominal pain is one of the most common causes of emergency department visits. Comprehensive patient assessment is required to identify the cause of abdominal pain. The origin of abdominal pain can be intra-abdominal or extra-abdominal. The majority of the cases with abdominal pain will have typical symptoms, suggesting intra-abdominal pain. A small subset of patients has atypical symptoms suggesting an extra-abdominal cause for the pain. Reports suggest that patients who presents with pain in the abdomen have the primary aetiology from the spinal column. This case report presents a 32-year-old male patient, with abdominal pain in advanced, recurrent Osteogenic Sarcoma (OGS) with spinal metastasis as the primary aetiology. Compression of nerve roots due to spinal bony metastasis lead to abdominal pain in the present case. Even though it was of spinal origin, clinically it micmicked to be of abdominal origin, so oncologists have to be vigilant in considering the rare causes of abdominal pain. Detailed history and clinical examination of the patients is ideal approach to identify the cause.
Keywords
Pain management, Palliative care, Quality of life
Case Report
The Medical Oncology department referred a 32-year-old male patient, a tobacco chewer and beedi smoker (10 years) with lower socio-economic status, to the pain and palliative care department. His chief complaint was lower abdominal pain (umbilical and peri umbilical region). Upon detailed evaluation, the pain was dragging and pricking type over the adjacent areas of the umbilicus. He scored his pain 8/10 on the Visual Analog Scale (VAS) score. The pain was present for one month, gradual onset, and progressive. For the last two weeks, the pain had increased. His pain increased during sitting and standing for his routine work for long. The pain was continuous in nature, disturbing his sleep in the past two weeks and significantly affecting his quality of life. He had a history of passing hard stools for three days. There was no history of nausea, vomiting, or urinary complaints. There was no history of abdominal surgery in the past. The patient also complained of pain in the lower back (since three weeks), VAS 5/10, dull aching type of pain. History suggested he was operated on for OGS of proximal humerus 1.5 years back. He also had received chemotherapy before surgery for his disease.
The patient was an average-built adult who was depressed and irritable due to his pain on physical examination. The examination revealed rigidity in both the iliac region and hypogastric region. The sensory examination over the abdominal wall was normal. There was no increase in pain with cough. There was no distension. Due to rigidity expressed by the patient, organomegaly could not be appreciated. Auscultation revealed normal bowel sounds. There was mild spinal tenderness. Digital rectal examination was normal. Systemic examination of other sites was uneventful. A provisional diagnosis of pain of abdominal origin was made. The initial pain management had anti-spasmodic (hyoscine butylbromide) thrice a day and non steroidal anti-inflammatory drugs (ibuprofen+paracetamol) thrice a day along with antacids (pantoprazole) once a day.
Laboratory tests like complete blood count, renal and liver function tests, erythrocyte sedimentation rate, C reactive protein, serum electrolytes, serum lipase, and amylase were normal. Electrocardiography monitoring showed no abnormalities. The patient was further subjected to Computed Tomography (CT) of his thorax, abdomen, and pelvis to look for the disease status. There was no visceral metastasis in the lungs, liver, or other organs; however, florid skeletal metastatic deposits in the dorsal spine, lumbar spine, sacral spine, right femur, and left sacrum were noted. Lytic lesions were over D3, D4, D7, D8, D9, L1, L3-5, S1, and S2 (Table/Fig 1). Of these lytic lesions, the most significant lesion was of the spinal process and body of L1 {Size of lesion was 12.1 mm; 8.2 mm3; significant nerve compression (By definition, the size of lesion more than 8 mm along with nerve compression more than 50% in the scan) was seen} (1). Magnetic resonance imaging of the whole spine revealed the lesions specifically causing the symptoms (Table/Fig 2). Axial imaging of the L1 lesion showed destruction of the body and spinal process causing compression of the nerve root (Table/Fig 3).
After the imaging evaluation, a final diagnosis of referred abdominal pain of spinal origin secondary to bony metastasis of OGS was made. Hence, the pain management course was changed to narcotics (morphine 10 mg every four hours), steroids (dexamethasone) thrice a day, antiemetic prokinetic agent (metoclopramide), laxatives (sodium picosulfate+liquid paraffin+milk of magnesia), and antacids (pantoprazole). He was further referred to the radiation oncology department for palliative radiotherapy, and was planned for bisphosphonate therapy in further follow-ups. These medications were given for 15 days. On follow-up, the patient was having pain of 2/10 on the VAS scale and was comfortable in terms of his sleep and other routine activities.
Discussion
Pain in the abdomen is the single most crucial symptom that hampers cancer patient’s quality of life (2). Abdominal pain is one of the most common causes of emergency department visits (4-5%) (3),4],(5). It is also the most common cause of admissions in palliative care patients [6,7]. Comprehensive patient assessment is required to identify the cause of abdominal pain. The origin of abdominal pain can be intra-abdominal or extra-abdominal. The majority of the cases with abdominal pain will have typical symptoms, suggesting intra-abdominal pain (8). A small subset of patients has atypical symptoms suggesting an extra-abdominal cause for the pain. Reports suggest that patients presented with pain in the abdomen with the primary aetiology from the spinal column (9),(10),(11),(12),(13),(14). Diagnostic uncertainty and risk of representation are two factors that make 2abdominal pain a problematic symptom (14),(15). Referred pain to various sites in the body can be understood on the basis of the dermatomal distribution of the nerves. The incidence of referred pain in cancer patients was between 8-20% in various studies (16),(17),(18),(19).
In a general overview idea, abdominal pain can be somatic (parietal) pain, visceral pain, or referred pain (20). In the present case report, the patient had rigidity on per abdominal examination, which was gave the impression that the pain was of somatic origin (20),(21),(22). A dragging type of pain in and around the umbilical region in index patient seemed to be a pointer towards lesion in the urinary bladder, kidney, or lower bowel (visceral) (23). A third reason explains abdominal pain, which is categorised as referred pain. Referred pain is pain that is felt away from the site of origin. It is because of the common anatomical origin or same nerve root innervations (24). Ruch’s convergent-projection theory reports that afferent visceral sensory pain fibres and somatic fibres enter the same spinal dorsal root ganglia segments of the spinal cord, causing misinterpretation by the central nervous system about the origin of the pain (24),(25).
The present case had the most significant lytic lesion of the L1 spinal process and body metastasis which was compressing the nerve root, causing lower abdominal pain. Previous reports of thoracic tumours, schwannoma, and meningioma of the spinal cord have reported similar findings (11),(12),(13). A course of steroids and escalating the pain medications to narcotics relieved his pain completely, suggesting the origin of pain was spinal metastasis and not intra-abdominal. But, it is also important to note that a minor proportion of patients will have abdominal pain, which is of extra-abdominal origin. Therefore, detailed history, physical examination of the patient presented with abdominal pain, and appropriate investigations are crucial in identifying the cause and proper management of the patients.
Conclusion
In the present case, abdominal pain in and around the umbilical region was of spinal origin. Bony metastasis in the spinal column can lead to compression of nerve roots and present as abdominal pain. Clinicians have to be vigilant in identifying such causes. Early identification and prompt treatment will benefit the patients in improving their quality of life.
Reference
| 1. | Singleton JM, Hefner M. Spinal cord compression. [Updated 2022 Feb 17]. In: Stat Pearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2022 Jan.
| 2. | Cain KC, Headstrom P, Jarrett ME, Motzer SA, Park H, Burr RL, et al. Abdominal pain impacts quality of life in women with irritable bowel syndrome. Am J Gastroenterol. 2006;101(1):124-32.
[ CrossRef] [ PubMed] | 3. | Cartwright SL, Knudson MP. Evaluation of acute abdominal pain in adults. Am Fam Physician. 2008;77(7):971-78.
| 4. | Falch C, Vicente D, Häberle H, Kirschniak A, Müller S, Nissan A, et al. Treatment of acute abdominal pain in the emergency room: A systematic review of the literature. Eur J Pain. 2014;18(7):902-13.
[ CrossRef] [ PubMed] | 5. | Macaluso CR, McNamara RM. Evaluation and management of acute abdominal pain in the emergency department. Int J Gen Med. 2012;5:789-97.
[ CrossRef] [ PubMed] | 6. | Koo MM, von Wagner C, Abel GA, McPhail S, Hamilton W, Rubin GP, et al. The nature and frequency of abdominal symptoms in cancer patients and their associations with time to help-seeking: Evidence from a national audit of cancer diagnosis. J Public Health. 2018;40(3):e388-95.
[ CrossRef] [ PubMed] | 7. | Okusaka T, Okada S, Ueno H, Ikeda M, Shimada K, Yamamoto J, et al. Abdominal pain in patients with resectable pancreatic cancer with reference to clinicopathologic findings. Pancreas. 2001;22(3):279-84.
[ CrossRef] [ PubMed] | 8. | Holtedahl K, Hjertholm P, Borgquist L, Donker GA, Buntinx F, Weller D, et al. Abdominal symptoms and cancer in the abdomen: Prospective cohort study in European primary care. Br J Gen Pract. 2018;68(670):e301-10.
[ CrossRef] [ PubMed] | 9. | Lyons M, Windgassen E, Kinney C, Johnson D, Birch B, Boucher O. Thoracic meningioma masquerading as chronic abdominal pain. Turk Neurosurg. 2012;22(3):365-67.
| 10. | Fakhouri F, Ghazal A, Alnaeb H, Hezan R, Araj J. Spinal-epidural abscess presenting as an acute abdomen in a child: A case report and review of the literature. Asian J Neurosurg. 2018;13(4):1247-49.
[ CrossRef] [ PubMed] | 11. | Jooma R, Torrens MJ, Veerapen RJ, Griffith HB. Spinal disease presenting as acute abdominal pain: Report of two cases. Br Med J. 1983;287(6385):117-18.
[ CrossRef] [ PubMed] | 12. | Park JE, Chung ME, Song DH, Choi HS. Inexplicable abdominal pain due to thoracic spinal cord tumour. Ann Rehabil Med. 2014;38(2):273-76.
[ CrossRef] [ PubMed] | 13. | Yang I, Paik E, Huh NG, Parsa AT, Ames CP. Giant thoracic schwannoma presenting with abrupt onset of abdominal pain: A case report. J Med Case Rep. 2009;3(1):88.
[ CrossRef] [ PubMed] | 14. | Clinical policy: Critical issues for the initial evaluation and management of patients presenting with a chief complaint of nontraumatic acute abdominal pain. Ann Emerg Med. 2000;36(4):406-15.
[ CrossRef] [ PubMed] | 15. | Holland KJ, Bennett WEJ. Narcotic and antidepressant use and hospital readmission rates in children with functional abdominal pain. Clin Pediatr. 2017;56(12):1104-08.
[ CrossRef] [ PubMed] | 16. | Vuong S, Pulenzas N, DeAngelis C, Torabi S, Ahrari S, Tsao M, et al. Inadequate pain management in cancer patients attending an outpatient palliative radiotherapy clinic. Support Care Cancer. 2016;24(2):887-92.
[ CrossRef] [ PubMed] | 17. | Di Maio M, Gridelli C, Gallo C, Manzione L, Brancaccio L, Barbera S, et al. Prevalence and management of pain in Italian patients with advanced non smallcell lung cancer. Br J Cancer. 2004;90(12):2288-96.
[ CrossRef] [ PubMed] | 18. | Oh SY, Shin SW, Koh SJ, Bae SB, Chang H, Kim JH, et al. Multicenter, crosssectional observational study of the impact of neuropathic pain on quality of life in cancer patients. Support Care Cancer. 2017;25(12):3759-67.
[ CrossRef] [ PubMed] | 19. | Mitera G, Zeiadin N, Kirou-Mauro A, DeAngelis C, Wong J, Sanjeevan T, et al. Retrospective assessment of cancer pain management in an outpatient palliative radiotherapy clinic using the pain management index. J Pain Symptom Manage. 2010;39(2):259-67.
[ CrossRef] [ PubMed] | 20. | Mehta H. Abdominal Pain. Clin Pathways Emerg Med Vol I. 2016;22:329-45.
[ CrossRef] [ PubMed] | 21. | Flasar MH, Goldberg E. Acute abdominal pain. Med Clin North Am. 2006;90(3):481-503.
[ CrossRef] [ PubMed] | 22. | Carlberg DJ, Lee SD, Dubin JS. Lower abdominal pain. Emerg Med Clin North Am. 2016;34(2):229-49.
[ CrossRef] [ PubMed] | 23. | Chen JS, Kandle PF, Murray I, et al. Physiology, Pain. [Updated 2021 Jul 26]. In: StatPearls [Internet]. Treasure Island (FL): Stat Pearls Publishing; 2022 Jan.
| 24. | Arendt-Nielsen L, Svensson P. Referred muscle pain: basic and clinical findings. Clin J Pain. 2001;17(1):11-19.
[ CrossRef] [ PubMed] | 25. | Mense S. Neurobiological mechanisms of muscle pain referral. Schmerz. 1993;7(4):241-49. [ CrossRef] [ PubMed] |
DOI: 10.7860/JCDR/2022/53791.16390
Date of Submission: Jan 06, 2022
Date of Peer Review: Feb 05, 2022
Date of Acceptance: Mar 17, 2022
Date of Publishing: May 01, 2022
Author declaration:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 08, 2022
• Manual Googling: Mar 07, 2022
• iThenticate Software: Apr 02, 2022 (5%)
Etymology: Author Origin
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