Differential Diagnosis for Post-Intervention Epigastric Pain

The patient presents with strong epigastric pain radiating to the bases of the thorax and intrascapular region after an intervention for an extrauterine pregnancy, which was performed under spinal anesthesia. Considering her recent surgical history and symptoms, the following differential diagnoses are proposed:

• Single Most Likely Diagnosis

  • Pancreatitis: This condition is a strong consideration given the location and radiation of the pain. The patient's recent surgery, especially under spinal anesthesia, could potentially lead to hypoperfusion or direct trauma to the pancreas, triggering pancreatitis. The epigastric pain radiating to the back is a classic presentation.

• Other Likely Diagnoses

  • Pulmonary Embolism (PE): Although less likely given the description of the pain, PE is a significant concern post-surgery, especially in patients who have undergone recent pelvic surgery. The radiation of pain to the intrascapular area could be misleading, but the primary concern would be the acute onset of symptoms.
  • Gastritis or Peptic Ulcer Disease: These conditions could be exacerbated by stress from surgery, certain medications (like NSAIDs for pain), or the spinal anesthesia itself. The epigastric pain is consistent with these diagnoses, though the radiation pattern is less typical.
  • Musculoskeletal Pain: Postoperative pain, especially after spinal anesthesia, can sometimes present as musculoskeletal pain due to the positioning during surgery or the effects of the anesthesia.

• Do Not Miss Diagnoses

  • Aortic Dissection: Although rare, this is a catastrophic condition that could present with severe, tearing pain radiating to the back. Given the patient's recent surgery and potential for hypertension or other cardiovascular stressors, it's crucial not to miss this diagnosis.
  • Myocardial Infarction: The radiation of pain to the thorax could suggest cardiac involvement, especially if the patient has risk factors for coronary artery disease. Myocardial infarction can present atypically, especially in women.
  • Splenic Injury or Rupture: Given the recent abdominal surgery, there's a possibility of injury to adjacent organs like the spleen, which could cause severe abdominal and back pain.

• Rare Diagnoses

  • Diaphragmatic Injury: This could potentially cause referred pain to the shoulder or back due to irritation of the diaphragm or associated nerves.
  • Cholecystitis: Inflammation of the gallbladder could cause right upper quadrant pain radiating to the back, though this would be less directly related to the recent surgery for ectopic pregnancy.
  • Esophageal Rupture or Perforation: This would be an extremely rare complication but could present with severe chest and abdominal pain, especially if there was an issue with intubation during surgery under spinal anesthesia.