An Unusual Cause of Recurrent Abdominal Pain

Abstract

Lead poisoning has been recognized as a major public health risk. We present a case of middle aged female, who presented with recurrent episodes of severe abdominal pain, which remains obscure even after thorough clinical evaluation and extensive investigations. Lastly, blood lead levels came out to be significantly raised and diagnosis of lead intoxication was made convincingly. On reviewing the case, history of intake of herbal medication justified the diagnosis. Therefore, even though the diagnosis represents a challenge, a physician must always include this possibility in the differential diagnosis for cases with suggestive symptoms.

Keywords: Lead; Ras sindoor; Herbal medication; Pain abdomen

Introduction

Lead poisoning has been recognized as a major public health risk, particularly in developing Countries [1]. It may involve major organs. The following case report argument about GI presentation of lead toxicity.

Case Presentation

A 34 years old woman, Resident of North India and nurse by occupation presented to us with complaint of diffuse abdominal pain for last 3 days. Pain was acute onset, moderately severe in intensity, colicky, starting from lower abdomen, involving whole abdomen over few hours with increased severity. No precipitating and relieving factors were present. It was associated with non passage of flatus and stools for last 2 days, but was not associated with abdominal distention or vomiting.

Patient also gave history of similar episodes in last 2 months. No history of chronic drug intake, substance abuse or surgical intervention in past. She consulted a gynaecologist few months back for primary infertility, but no records were available.

On examination, vitals were stable and mild pallor was present per abdomen examination showed diffuse tenderness but no guarding or rigidity was present. Bowel sound were sluggish. Per rectal examination was normal.

Patient was admitted in Acute care unit and Urgent X ray Abdomen erect posture was performed which showed few dilated large bowel loops, but essentially ruled out perforation. She was started on conservative management in the form of restricted diet, IV fluids, enema and terpentine oil stooping.

Routine investigations showed moderate Anemia with Hemoglobin of 8 gm/dl (MCV- 72 fL) and low platelets (1.2 lakh/ mm3) with normal total leucocyte counts. Liver functions were also mildly deranged in form of transaminitis (SGOT/PT =72/67 IU/L) with normal renal functions and serum amylase/ lipase levels. CT Enterography was done which turned out to be normal.

Patient got improved with conservative measures after 2 days and was discharged on SOS pain killers and laxatives , to follow up for further evaluation.

Just 3 days after discharge , she again presented with similar nature of pain for last 2 days, not associated with vomiting / abdominal distention or non passage of flatus or stools. She was admitted and conservative management was started. Repeat CT Enterography and Angiography was done which was reported normal. Prepared full length Colonoscopy and Esophagogastroduodenoscopy were also performed on the following days, but were essentially normal. Routine investigations showed bicytopenia in form of Hb=9 gm/ dl and marginally low platelets. General blood picture showed predominantly microcytic cells with hypochromia and few cells showing basophilic stippling. Taking clue from that , serum lead levels was ordered , which came out to be raised (75μg/dl, five times the ULN). For making a consolidate diagnosis, it was repeated from another standard lab, which again came high (65μg/dl). Simultaneously urine porphyrin levels were done, which came out to be normal.

On reviewing the history , patient admitted to consumption of an ayurvedic preparation for last few months as an appetizer. On analyzing the preparation , it was found to contain Ras sindoor (Lead) as the principle ingredient . The suspected source of exposure in our patient was herbal-based medication (Figure 1). Though toxicological analysis was not performed, absence of any other source of poisoning and circumstantial evidence of herbal-based medicinal use, which have been widely reported to cause lead poisoning, supports our diagnosis.

    

    

    Figure 1: Herbal Preparation containing Ras Sindoor (Lead).