Case

A 42-year-old complains of abdominal pain that began intermittently about 6 months in the upper left quadrant.  Recently the pain has become low level constant in nature, with enhancement of the pain shortly after meals including a sharper mid left back pain most recently.  They also report heartburn that has been occurring during the previous year which is also more prominent shortly after meals now.  The patient has been self-medicating with over-the-counter antacids, which have been providing some relief. They states his stools have changed in color over the previous month and now are intermittently dark and tarry in consistency. Tests of the patient’s stool finds occult blood (‘occult blood’ is blood that is not visible to the naked eye). 

Question 3/3 - What is causing the back pain?

Click on your selected option(s) below  (correct = 2, over-thinking = 3+)

Case Complete

Correct!  Pain originating from the stomach most commonly refers to the epigastrium (which the patient describes as the upper left quadrant pain).  However it can also refer to the mid-back in the area inferior to the scapula.

Pain can also radiate to the right shoulder and armpit if the ulcers are also involving the duodenum.

Incorrect. While unrelated lower back pain is possible, as many experience bouts of LBP during their life, it would be highly coincidental for the back injury to exacerbate every time simultaneously with meals. LBP does not typically respond to antacids which the patient indicate has provided some relief. 

Incorrect. The greater sac is the area of the peritoneal cavity anterior and inferior of the stomach (i.e. everything that isn't the lesser sac).  Irritation of this peritoneum is peritonitis and would cause generalized abdominal pain rather than specific back pain.

Incorrect. The duodenal lumen is designed to receive gastric juices, the acidity of which are neutralized by the basic secretions of the Brunner's glands. Only in cases of glandular disruption or duodenal ulcers would there be duodenal lumen irritation.

Since this patient was diagnosed with peptic, not duodenal ulcers, we do not expect duodenal pain. When present, pain from the duodenum can refer to the mid-back, the right shoulder, and/or armpit.

Correct!  A posterior perforation of the stomach could leak gastric juices into the lesser sac (the region posterior to the stomach). These juices would irritate the parietal peritoneum of the posterior abdominal wall posterior to the stomach. Most parietal irritation is felt as sharp relatively well localized pain, which at this location is approximately mid back.