Abdominal pain in patients with hyperglycemic crises

https://doi.org/10.1053/jcrc.2002.33030Get rights and content

Abstract

Background: The aim of the study was to evaluate the incidence and prognosis of abdominal pain in patients with diabetic ketoacidosis (DKA) and hyperglycemic hyperosmolar nonketotic state (HHS). Abdominal pain, sometimes mimicking an acute abdomen, is a frequent manifestation in patients with DKA. The prevalence and clinical significance of gastrointestinal symptoms including abdominal pain in HHS have not been prospectively evaluated. Materials and Methods: This is a prospectively collected evaluation of 200 consecutive patients with hyperglycemic crises admitted to a large inner-city teaching hospital in Atlanta, GA.We analyzed the admission clinical characteristics, laboratory studies, and hospital course of 189 consecutive episodes of DKA and 11 cases of HHS during a 13-month period starting in October 1995. Results: Abdominal pain occurred in 86 of 189 patients with DKA (46%). In 30 patients, the cause of abdominal pain was considered to be secondary to the precipitating cause of metabolic decompensation. Five of them required surgical intervention including 1 patient with Fournier's necrotizing fasciitis, 1 with cholecystitis, 1 with acute appendicitis, and 2 patients with perineal abscess.The presence of abdominal pain was not related to the severity of hyperglycemia or dehydration; however, a strong association was observed between abdominal pain and metabolic acidosis. In DKA patients with abdominal pain, the mean serum bicarbonate (9 ± 1 mmol/L) and blood pH (7.12 ± 0.02) were lower than in patients without pain (15 ± 1 mmol/L and 7.24 ± 0.09, respectively, both P < .001). Abdominal pain was present in 86% of patients with serum bicarbonate less than 5 mmol/L, in 66% of patients with levels of 5 to less than 10 mmol/L, in 36% of patients with levels 10 to less than 15 mmol/L, and in 13% of patients with bicarbonate levels 15 to 18 mmol/L. Patients with DKA and abdominal pain had a more frequent history of alcohol (51%) and cocaine abuse (13%) than those without abdominal pain (24% and 2%, respectively, both P < .001). One patient with HHS reported nausea and vomiting on admission, but abdominal pain was not reported in any patient with HHS. Conclusions: Gastrointestinal manifestations including abdominal pain are common in patients with DKA and are associated with severe metabolic acidosis and with a history of alcohol or cocaine abuse, but not with the severity of hyperglycemia or dehydration. Our study indicates that investigation of the etiology of abdominal pain in DKA should be reserved for patients without severe metabolic acidosis or if the pain persists after the resolution of ketoacidosis. Copyright 2002, Elsevier Science (USA). All rights reserved.

Section snippets

Materials and methods

This was a prospective evaluation of 200 consecutive patients with hyperglycemic crises admitted to Grady Memorial Hospital in Atlanta during a 13-month period starting in October 1995. Of the 200 patients, 189 patients (95%) met the diagnostic criteria for DKA (111 men and 82 women) and 11 patients were admitted with HHS (4 men and 7 women). The diagnosis of DKA was established in the emergency department by a plasma glucose level greater than 13.8 mmol/L (250 mg/dL), a serum bicarbonate level

Results

The study population included 189 patients with DKA and 11 patients with HHS. Their clinical characteristics are shown in Table 1. Abdominal pain was reported in 86 of 189 patients with DKA (46%). Patients with DKA and abdominal pain were younger (37 ±; 1 yr, standard error of mean) than patients without abdominal pain (41 ± 2 yr, P = .03). The mean duration of diabetes and number of patients with newly diagnosed diabetes were similar between DKA patients with and without abdominal pain. Pain

Discussion

The evaluation of abdominal pain in patients with DKA may be difficult and frequently challenges the physicians' clinical acumen. Faced with a seriously ill patient, the clinician must judge whether the abdominal pain is a consequence of the metabolic decompensation or if the pain signals a serious underlying intra-abdominal process that may have precipitated the development of ketoacidosis. Because of the fear of missing an intra-abdominal medical or surgical process, extensive laboratory and

References (35)

  • TJ Wachtel et al.

    Hyperosmolarity and acidosis in diabetes mellitus: A three-year experience in Rhode Island

    J Gen Intern Med

    (1991)
  • PS Hamblin et al.

    Deaths associated with diabetic ketoacidosis and hyperosmolar coma 1973-1988

    Med J Aust

    (1989)
  • AM Schindler et al.

    Prolonged abdominal pain in a diabetic child

    Hosp Pract (Off Ed)

    (1988)
  • EJ Barrett et al.

    Gastrointestinal manifestations of diabetic ketoacidosis

    Yale J Biol Med

    (1983)
  • IW Campbell et al.

    Abdominal pain in diabetic metabolic decompensation. Clinical significance

    JAMA

    (1975)
  • LA Katz et al.

    Gastrointestinal manifestations of diabetes

    N Engl J Med

    (1966)
  • FY Huang et al.

    Abdominal pain in diabetic ketoacidosis: Report of four cases

    Zhonghua Minguo Xiaoerke Yixue Zazhi

    (1990)
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    Address reprint requests to Guillermo E. Umpierrez, MD, Associate Professor of Medicine, Department of Medicine, University of Tennessee Health Science Center, 951 Court Ave, Rm 340M, Memphis, TN 38163.

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