Thursday, July 7, 2016

Abdominal pain in 62 year old male runner during 50 mile running race

               History:  62 year old male runner with no significant medical history and not on any current medications.   The athlete was competing in a 50 mile race.  He is an experienced endurance runner having raced for over 30 years.   He lives at sea level and was running at altitude (6000-8000 feet).
               Approximately mile 18  of the race, he ate half of a sandwich and cookies at our aid station.  About 1 mile later, he developed epigastric abdominal pain/lower chest pain.   He had a normal bowel movement with no blood or diarrhea.  He did force himself to vomit with no relief.    Because of pain radiating to his shoulder, he did take an aspirin that he had with him.  He walked back to our aid station under his own power

               Exam:   The runner was in moderate discomfort upon presentation to the medical tent.    He rated his pain as 7/10 in severity over his epigastric area and had pain radiating to his right shoulder.  Vital signs with a oral temperature of 97.8 F, BP 120/78 and pulse of 65 BPM.   On physical exam, he did have diffuse abdominal guarding but no rebound tenderness and no masses.

               Treatment/Disposition:  The runner had already taken 325 mg of aspirin prior to presenting to the medical tent.  He was given some calcium carbonate tabs for his pain which provided no relief.    After discussion with the runner, he was driven to the closest emergency room (approximately 30 minutes away by truck over forest roads) with one of the treating physicians.

               Follow up care: Upon arrival at the emergency room, his pain had increased to 8/10 in severity.   He was given dilaudid, ondansetron, and nitroglycerine .    Labs revealed an elevated WBC count of 15.7 with a left shift.  His stool was heme positive.  Troponin was mildly elevated at 0.13 ng/mL (0.00-0.05 range) as was serum amylase at 186 (23-125).  LFTs were normal.   ECG showed no evidence of ischemic changes.  CT of the abdomen/pelvis did show a mildly distended gallbladder with a thickened wall and pericholecystic fluid.   The runner was transferred to another hospital and had laparoscopic cholecystectomy performed.  Pathology did reveal of acute gangrenous acalculous cholecystitis.  He was discharged one day later and continued to improve.
Take Home Points:  
1) While abdominal pain is very common in runners, acute cholecystitis in an athlete has not been reported often in the medical literature. 
               2)  Based on the symptoms and history alone, it was initially difficult to rule out cardiac causes for his pain.   His physical exam findings, however,  made us more concerned for GI issues which, in turn, allowed us to transport him by ground as opposed to helicopter.
               3)  Heme positive stools are fairly common after long exertion (8-85% of athletes).