An Unusual Case of Refractory Abdominal Pain: Don't Miss the Point.

Question: A 47-year-old man with past medical history of hypertension, hyperlipidemia, asthma, migraines, and gastroesophageal reflux disease presented with intermittent diarrhea and epigastric abdominal pain of 1 month duration. He consumed 1 to 2 alcohol drinks up to 3 times a week. He was evaluated by an outside facility, with subsequent work-up including normal computed tomographic (CT) abdomen/pelvis scan, esophagogastroduodenoscopy, and colonoscopy. Despite this, he developed nausea, vomiting, and weight loss. He then underwent an abdominal ultrasound and a gastric emptying study, which were unrevealing. A hepatobiliary iminodiacetic acid scan revealed a reduced gallbladder ejection fraction of 12%, and the patient was advised to have a cholecystectomy. Afterward, he was evaluated by our facility for a second opinion; further work-up including fecal elastase, fecal fat, and fecal calprotectin was normal. The patient was diagnosed with diarrhea-predominant irritable bowel syndrome (IBS-D) and was started on rifaximin and a low–fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet. After treatment, his abdominal pain persisted and became localized to the left upper quadrant. He began to feel a popping sensation in the lower sternum, especially when bending forward. Upon further review of his history, he was noted to previously work as a bull rider and was involved in multiple motor vehicle accidents, but without major injury involving the abdomen. To further evaluate his abdominal symptoms, a CT scan of the chest was ordered (Figures A and B).What is the appropriate diagnosis for this patient? Look on page 892 for the answer and see the Gastroenterology website (www.gastrojournal.org) for more information on submitting to Gastro Curbside Consult. Xiphodynia, also known as xiphoid syndrome and xiphoidalgia, was diagnosed in this patient. Physical examination revealed tenderness on palpation of the xiphoid process. His chest CT revealed an elongated anteriorly curved xiphoid process. Because of ongoing symptoms and a worsening popping sensation with bending forward, he underwent xiphoidectomy, and his abdominal pain symptom resolved without recurrence over more than a year later. This case highlights the importance of a xiphoid examination in patients with epigastric abdominal pain. Unfortunately, evaluating the xiphoid process is not routine and the diagnosis is commonly missed. Xiphodynia was first reported in 1712, although few case studies have characterized this disorder in the literature.1Lipkin M. Fulton L.A. Wolfson E.A. The syndrome of the hypersensitive xiphoid.N Engl J Med. 1955; 253: 591-597Crossref PubMed Google Scholar, 2Olivencia-Yurvati A.H. Xiphodynia surgical management.Int Surg. 2017; 102: 412-416Crossref Scopus (3) Google Scholar, 3Maigne J.Y. Vareli M. Rousset P. Cornelis P. Xiphodynia and prominence of the xyphoid process. Value of xiphosternal angle measurement: three case reports.Joint Bone Spine. 2010; 77: 474-476Crossref PubMed Scopus (19) Google Scholar Xiphodynia pain typically occurs deep in the retrosternal chest and may radiate into the back, through the shoulders, over the precordium, or into the epigastrium.1Lipkin M. Fulton L.A. Wolfson E.A. The syndrome of the hypersensitive xiphoid.N Engl J Med. 1955; 253: 591-597Crossref PubMed Google Scholar Diagnosis can be challenging because xiphodynia pain may mimic various causes of chest and abdominal pain. In addition, almost one-half of patients with xiphodynia have concomitant cardiac or gastrointestinal diseases, eg, coronary artery disease, cholelithiasis, or duodenal ulcer.1Lipkin M. Fulton L.A. Wolfson E.A. The syndrome of the hypersensitive xiphoid.N Engl J Med. 1955; 253: 591-597Crossref PubMed Google Scholar We suspect that our patient had xiphodynia with concomitant IBS-D. The treatment of low-FODMAP diet improved diarrhea symptoms, but abdominal pain resolved only after xiphoidectomy. A detailed physical examination may guide clinicians to correctly diagnose the disease, although diagnostic imaging can also be helpful. Previous literature reported significant angulation of the xiphoid process in 30% of cases,2Olivencia-Yurvati A.H. Xiphodynia surgical management.Int Surg. 2017; 102: 412-416Crossref Scopus (3) Google Scholar with a xiphosternal angle of 105° to 135° compared with a mean of 172° in the normal population.3Maigne J.Y. Vareli M. Rousset P. Cornelis P. Xiphodynia and prominence of the xyphoid process. Value of xiphosternal angle measurement: three case reports.Joint Bone Spine. 2010; 77: 474-476Crossref PubMed Scopus (19) Google Scholar Our case demonstrated a xiphosternal angle of 100° (Figure C). In the few cases that have been reported, the condition was thought to be related to sports injuries, blunt traumas, childbirth, or overuse of abdominal muscles.2Olivencia-Yurvati A.H. Xiphodynia surgical management.Int Surg. 2017; 102: 412-416Crossref Scopus (3) Google Scholar It is possible that our patient experienced recurrent microtrauma to his xiphoid process as a bull rider or from his multiple motor vehicle accidents. Treatment is typically conservative with the use of analgesics, elastic belts, heat and cold therapy, laser and ultrasound therapy, and skeletal/soft tissue manipulation by physical therapy. Alternatively, local anesthetics can temporarily provide relief. In individuals that fail medical management, xiphoidectomy can be considered.