Health Questions and Answers

Question: A patient with severe abdominal pain is found to be in diabetic ketoacidosis (DKA). How do I decide whether the abdominal pain is a manifestation of the DKA or whether a surgical condition has precipitated DKA?

Answer: Patients with established DKA often present to the Emergency Room with severe abdominal pain. Physical examination reveals a dehydrated, hyperpneic patient with generalized abdominal tenderness and guarding, which may progress to boardlike rigidity. Bowel sounds usually are reduced or absent, and rebound tenderness may be noted. Although the precise mechanism of abdominal pain and ileus in patients with DKA is not well understood, hypovolemia, hypotension, and a total body potassium deficit probably contribute. An acute surgical lesion may initiate DKA; nevertheless, most patients have no such pathology. Symptoms characteristically resolve as medical treatment restores the patient to biochemical homeostasis. Treatment of the DKA must precede any surgical intervention because of the extremely high intraoperative mortality among patients not so stabilized. Similarly, among patients with alcoholic ketoacidosis, the most common complaints are gastrointestinal, including abdominal pain. Objective signs are typically absent, however, and when found reliably point to concomitant problems, such as pancreatitis, hepatitis, gastritis, or pneumonia.

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