Case Presentation:
An 85‐year‐old woman with chronic obstructive lung disease, hypertension, and a history of cere‐brovascular accident presented to the hospital with chest pain for 1 day that was worse with deep inspiration. She also had fever, chills, and increased productive cough with yellowish sputum. Her review of systems was negative except for the above. Her laboratory workup included a positive D‐dimer, and she underwent a CT angiogram, which was negative for pulmonary embolism but positive for right lower lobe infiltrate and moderate to severe emphysema. She was admitted and started on antibiotics. She continued to complain of chest pain on and off and was ruled out for myocardial infarction. On hospital day 2, pain was more in the epigastric area and was associated with mild abdominal distention and mild epigastric tenderness on exam. Repeat chest x‐ray was unchanged, and KUB x‐ray was unremarkable. Repeat cardiac enzymes were negative. On hospital day 3, the patient had acute onset of shortness of breath with increasing oxygen requirement and worsening chest pain. She was noted to have atrial fibrillation with a rapid ventricular rate. Her rate was controlled with intravenous metoprolol. Exam, at that time, was positive for distended abdomen and diffuse abdominal pain with rebound. Lactate level was 3.6. Because of concern for bowel ischemia from a thromboembolic event, an abdominal CT scan with contrast was obtained, which was positive for a large amount of free air and ascites, consistent with a perforated viscous. The surgery team was consulted and evaluated the patient emergently. The patient was taken to the OR emergently for laparotomy surgery and was found to have a perforated gastric ulcer, which was repaired. The postoperative course was complicated by respiratory failure requiring mechanical ventilation. The patient died after a prolonged course in the intensive care unit.
Discussion:
The frequency of perforated peptic ulcer is increasing among older patients because of the high prevalence of Helicobacter pylori infection and increased non‐steroidal anti‐inflammatory drug (NSAID) use. Perforation can happen without a history of ulcer, especially in older patients with NSAID usage. Therefore, prevention, early identification, and early surgical intervention of perforated ulcer in the elderly are very important. Our patient was an elderly woman who presented with chest pain and was found to have pneumonia. Her pain was described as pleuritic in nature. With a negative cardiac workup, the pain was attributed to pneumonia. However, about one third of chest pains are caused by gastrointestinal diseases. On her third day of hospitalization, she developed atrial fibrillation with rapid ventricular rate, which may have been a result of an acute or impending bowel perforation.
Conclusions:
This case is an important reminder that gastrointestinal pathology should always be considered in the differential diagnosis of chest pain in the elderly even if there is an alternative explanation for the pain.
Disclosures:
Z. Al‐Mansour ‐ none; X. Le ‐ none; J. Jahanmir ‐ none