History: A 35 year old male was seen on our service with complaints of dizziness, unsteady gait and nausea that was brought on by movement, especially getting out of bed or rolling over in bed. These symptoms came on suddenly after a cholecystectomy 4 months previously. He had been suffering from chronic R upper quadrant abdominal pain for 19 months with increased pain after eating and with walking after meals. The cholecystectomy did not relieve his discomfort.
Examination: Examination confirmed a Right sided posterior canalisthiasis (BPPV) and a repositioning manoever was performed that rendered him immediately asymptomatic for his dizziness, unsteady gait and nausea. The abdominal examination revealed point tenderness in the upper right abdominal quadrant. There were no masses, lymphadenopathy or splenohepatomegaly. Flexing the patients neck while in the supine position with digital pressure over the point of tenderness caused the patient to scream out with serve pain and a transient resultant loss of consciousness. There was no cardiac pathology. Gait examination revealed a loss of anterior inferior glide of the R sacrum at the ilium in all phases of gait. The R sacroiliac was extremely tender to palpation
Diagnosis: BPPV and Sacroiliac Syndrome
Treatment: The R Superior Sacroiliac joint was reduced by manipulation in the L lateral decubitus position. Normal gait was observed post manipulative reduction and the sacroiliac joint was no longer tender. Abdominal examination was observed to be without discomfort and I could not reduplicate the point tenderness with and without flexing of the head. The patient exclaimed that his gall bladder pain had been “cured”. He was seen again in one month time and described no abdominal discomfort and no dizziness or gait abnormalities. He was able to eat all foods since the manipulation of the R sacroiliac joint without problems. He was contacted 6 months later and remained asymptomatic and enjoying his life.
Discussion: Musculoskeletal complaints can mimic organopathology. Provocative manoeuvres that will place long axis torque on musculature can be helpful in differentiating a musculoskeletal problem from an underlying pathology. Manipulation of joints that might reduce stressors on musculotendinous structures can relieve pain and increase function. A differential diagnosis of musculoskeletal pain syndromes should always be considered in all patients with abdominal pain presentation. The procedures to differentiate syndromes are inexpensive and are cost savings when they are conclusive.