The Leading Diagnosis

2390
derlying hematologic disorder (such as sickle cell
disease, thalassemia, or glycerophosphoryl diester
phosphodiesterase deficiency, all of which are
more common in blacks) might also underlie her
previously diagnosed anemia. Other less common
causes of small-intestinal bleeding and pain include
tumors, mesenteric ischemia, Meckel’s diverticulum
(although the pain is typically less severe),
and endometrial deposits along the intestinal tract
with pain that may correlate with the periodicity
of the menses.
On examination, the patient was afebrile, with a
heart rate of 100 beats per minute, a respiratory
rate of 16 breaths per minute, an oxygen saturation
of 100% while she was breathing ambient
air, and a blood pressure of 115/65 mm Hg. Her
height was 65 in. (165.1 cm), and she weighed
115 lb (52.3 kg). She was restless on the gurney,
clutching her abdomen. Her sclerae were anicteric,
and her conjunctivae were pale. The oropharynx
was normal, and the neck was supple, without
lymphadenopathy. The heart sounds were
regular, and the lungs clear. There was no chestwall
or flank tenderness. Abdominal examination
revealed hyperactive bowel sounds and diffuse
tenderness on palpation without rebound
tenderness, organomegaly, or masses. The rectal
examination showed no masses. A stool sample
was brown and was negative for occult blood.
The pelvic examination revealed no masses, cervical
motion, or adnexal tenderness. There was no
edema in the legs. The neurologic examination
was normal.
The observations that the patient is restless (as
compared with the still appearance that would be
expected in diffuse peritonitis), that she is clutching
her abdomen but not avoiding touch, and that
she has hyperactive bowel sounds and no rebound
tenderness argue against generalized peritonitis,
although these findings do not rule out early peritoneal
inflammation. On this occasion, there is
no occult blood in her stool, but conjunctival pallor
suggests profound anemia. Given her history,
I continue to be concerned about gastrointestinal
blood loss, and I wonder in particular about inflammatory
bowel disease as the cause of her condition.
Admission to the hospital is warranted to determine
the cause of her severe pain. A negative
serum human chorionic gonadotropin (hCG) test
would rule out ectopic pregnancy. If routine labo-
T h e n e w e ng l a nd j o u r na l o f m e dic i n e
n engl j med 357;23 www.nejm.org december 6, 2007
ratory tests do not point to the source of pain,
urgent abdominal imaging with computed tomography
(CT) is indicated. CT is more sensitive than
plain radiography for detecting the presence and
source of intraabdominal free air, and it may reveal
small-bowel obstruction or bowel-wall thickening.
This latter result, although nonspecific,
would be compatible with bowel-wall edema due
to ischemia, infection, inflammation, or neoplastic
infiltration. Given my low suspicion for infection,
this finding might lead to endoscopic evaluation
of the bowel.
The serum sodium, potassium, and calcium levels
were normal. The blood urea nitrogen level
was 9 mg per deciliter (3.2 mmol per liter), creatinine
0.6 mg per deciliter (53 μmol per liter), lipase
22 U per liter (normal range, 1 to 60), aspartate
aminotransferase 25 U per liter (normal
range, 8 to 31), alanine aminotransferase 10 U
per liter (normal range, 7 to 31), alkaline phosphatase
55 U per liter (normal range, 39 to 117),
and total bilirubin 0.3 mg per deciliter (5.1 μmol
per liter) (normal range, 0.1 to 1.2 mg per deciliter
[2 to 21 μmol per liter]). The white-cell count
was 6400 per cubic millimeter, with 87% neutrophils,
9% lymphocytes, and 4% monocytes. The
hematocrit was 23%, with a mean corpuscular
volume of 65 μm 3 . A peripheral-blood smear
showed 2+ microcytosis, 2+ hypochromia, and
no other abnormal cells. A serum test for hCG
was negative. Dipstick testing of a specimen of
voided urine revealed a specific gravity of 1.022
and a pH of 5.0; tests for protein, leukocyte esterase,
nitrites, and blood were negative. Urine
microscopical examination showed no white or
red cells.
These results rule out ectopic pregnancy. Pyelonephritis
would be unlikely without pyuria, and, although
no amylase level was reported, the normal
lipase level argues against pancreatitis. Advanced
cholecystitis and cholangitis are unlikely given the
normal results of the liver-function tests. A normal
white-cell count soon after the onset of symptoms
does not rule out bowel obstruction or inflammatory
processes such as appendicitis. The
most salient findings are the low hematocrit and
mean corpuscular volume. Iron deficiency and
thalassemia are the most common causes of these
values. In this patient with metromenorrhagia and
bleeding from the rectum, iron deficiency is a more
likely cause. Although her menorrhagia could ac-
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