Exertional Abdominal Pain in a Crew Athlete! Vanessa Lalley-DeMong DO Andrew Kusienski DO Melissa Tabor DO! HISTORY OF PRESENT ILLNESS! 19 year old Division II sophomore female crew athlete presents to the Sports Medicine Clinic with lower abdominal pain that occurred after racing the previous weekend.! Raced six times over the weekend. Lower abdominal pain occurred for 20 minutes after each race, then spontaneously resolved.! Describes pain as sharp, burning and cramping. Had one occurrence of this type of pain 1 year ago after a race.! Not reproduced during practice, other races or daily activities.! Tried Aleve and ice, is unsure if these helped. She finds not moving improves pain.! REVIEW OF SYSTEMS! General: (+) one episode occurred 1 year previously and 10 days prior to office visit while racing. (-) changes in weight.! HEENT: (-) Headaches. (-) dizziness.! CV: (-) Chest pain.! Resp: (-) Shortness of breath.! GI: (+) feels the need to burp. (+) decreased appetite with pain. (+) nausea only with pain. (-) vomiting, diarrhea or loose stools after pain. (-) dark or tarry stools. (-) association with certain foods or after eating.! GU: LMP 3 days prior to visit. (-)history of UTIs, (-) urinary urgency or hesitation, (-) polyuria, (-) hematuria. (-) vaginal discharge, odor, burning, itching.! MSK: (-) Low back pain. (-)radiating pain. (-)numbness, tingling or weakness.! Metabolic/Endocrine: states she hydrates adequately without polydipsia.! Psych: states she is happy with her current weight. Gets nervous prior to racing, but nervousness does not correlate with abdominal pain.! 1!
MEDICAL HISTORY! Currently healthy! Medications: none, NKDA! Student-Athlete, an experienced member of the crew team.!! Sexual Activity: Denies ever being active.! Denies tobacco/etoh/drugs.! Family History of Diabetes Mellitus II! PHYSICAL EXAM! VS: T 97.6 F!P 56!BP 122/62!RR 16!! Gen: NAD, AAOX3! CV: RRR S1/S2, no murmurs, rubs, gallops!! Abdomen: Soft. No masses or bulges with straining or sitting up. No umbilical or inguinal hernia. (-)McBurney s. (-) Murphy s!! Pelvic: (-) labial or vaginal lesions. (+) blood - menstruating at time of exam, no discharge. No enlarged ovaries or uterus. No cervical motion tenderness. No ovarian tenderness.! MSK: bilateral psoas tenderpoints.! DIFFERENTIAL DIAGNOSIS! GI: gastritis, colitis, H. pylori, hepatitis, peptic ulcer disease, delayed gastric emptying, IBS, constipation, pancreatitis, pancreatic duct obstruction or spasm, esophageal spasm, cholecystitis, cholelithiasis, diverticulitis.! GU: cystitis, ovarian torsion, ovarian cysts, fibroids, endometriosis, ectopic, salpingitis, TOA, STI.! CV: ischemia, hypoprofusion! Endocrine: thyroid disorder! Neurologic: nerve compression.! Heme/Onc: GI cancer, iron-deficiency anemia.! Musculoskeletal: abdominal muscle or psoas strain.! Iatrogenic: dehydration, trauma, food intolerance.! Psychologic: performance anxiety.!!! 2!
DIAGNOSTIC TESTS! Urine Pregnancy: Negative.! Urine Dipstick and Bloodwork: Negative.! Transabdominal pelvic ultrasound: Negative.! CT Abdomen and Pelvis with and without contrast: Negative.! HIDA: Negative.! RUQ Ultrasound: (+) Murphy s sign, otherwise negative.! Endoscopy: Mild gastritis.! MRA Abdomen: Mild to moderate ostial narrowing of the celiac trunk, likely due to compression by arcuate ligament of the diaphragm.! Duplex Scan of the celiac artery and SMA: elevated celiac artery velocity.!!! CELIAC ARTERY COMPRESSION SYNDROME! Median Arcuate Ligament Syndrome!! Celiac Axis Syndrome!! Dunbar Syndrome! 3!
CLASSIC CHARACTERISTICS! Abdominal pain after eating! Nausea, vomiting, diarrhea! Weight loss! Occasional abdominal bruit! Delayed gastric emptying! Exercise-induced in young athletes! PATHOLOGY! Not 100% understood! More prevalent in women! CONGENITAL! Seen in families and twins! CELIAC NERVE PLEXUS! DIAGNOSTIC EVALUATION! Duplex Ultrasound! Elevated velocities indicate stenosis! Does not differentiate intrinsic vs. extrinsic stenosis! CT Angiography or MR Angiography! Inspiratory and expiratory arteriography! 4!
TREATMENT! Surgery! Laproscopic median arcuate ligament release! Open median arcuate ligament release! To revascularize or not?! 5!
Exertional Abdominal Pain in a Crew Athlete! Referred to vascular surgeon! Laproscopic median arcuate ligament release! 8 weeks post-op returned to racing! Member of the 2013 National Championship Crew Team.! QUESTIONS?! 6!
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