Question

65-year-old white man presents to the emergency department with a hugely distended abdomen. He states that his abdomen has been progressively distending over the past 4 days. He describes decreased appetite and nausea but no vomiting. He also describes abdominal discomfort and mild diffuse pain. He states that the last time he had a bowel movement was 5 days ago. He is passing flatus.

The patient denies any fever, chills, or chest pain. He mentions that he has difficulty breathing. His medical history is significant for hypothyroidism, for which he is taking levothyroxine. He has also been diagnosed with chronic obstructive pulmonary disease (COPD), for which he uses an albuterol inhaler and a budesonide and formoterol inhaler. He also has hypertension, for which he takes amlodipine, and hyperlipidemia, for which he takes atorvastatin.

His past surgical history is significant for a meniscal tear repair in his right knee. The patient reports a 50–pack-year smoking history and denies any significant history of alcohol use or illegal drug use.

He was recently admitted to the hospital for a COPD exacerbation and acute bronchitis. He had a prolonged stay in the hospital (7 days) and was treated with intravenous methylprednisolone, levofloxacin, albuterol, budesonide, and arformoterol. He was discharged home on a tapering course of oral prednisone 4 days ago.

Physical Examination and Workup

Upon arrival to the emergency department, the patient has a temperature of 98.9°F (37.16°C), a heart rate of 104 beats/min, a respiratory rate of 22 breaths/min, blood pressure of 112/84 mm Hg, and 92% oxygen saturation on room air.

Upon physical examination, he appears uncomfortable and is lying in the supine position; he has dry oral mucosa. Abdominal examination reveals a very large, distended abdomen with apparent mild diffuse tenderness to palpation and without any rebound tenderness or guarding. Bowel sounds are tympanic. His abdominal pain appears out of proportion to the physical examination findings.

His laboratory values are as follows:

• White blood cell count: 14,000 cells/µL (reference range, 4500-11,000 cells/µL)
• Hemoglobin level: 13.9 g/dL (reference range, 13.5-17.5 g/dL)
• Hematocrit concentration: 37% (reference range, 45%-52%)
• Platelet count: 306,000 cells/µL (reference range, 150,000-450,000 cells/µL)
• Sodium level: 135 mEq/L (reference range, 135-145 mEq/L)
• Potassium level: 3.5 mmol/L (reference range, 3.6-5.2 mmol/L)
• Chloride level: 107 mmol/L (reference range, 98-106 mmol/L)
• Blood urea nitrogen (BUN) level: 43 g/dL (reference range, 7-20 mg/dL)
• Creatinine level: 1.51 mg/dL (reference range, 0.6-1.2 mg/dL)
• Glucose level: 102 mg/dL (reference level, < 100 mg/dL)
• Aspartate aminotransferase level: 46 U/L (reference range, 10-40 U/L)
• Alanine aminotransferase level: 41 U/L (reference range, 7-56 U/L)
• Alkaline phosphatase level: 142 IU/L (reference range, 44-147 IU/L)
• Amylase level: 25 U/L (reference range, 23-85 U/L)
• Lipase level: 19 U/L (reference range, 0-160 U/L)
• Lactic acid level: 0.7 mmol/L (reference range, 0.5-1 mmol/L)

Which of the following in the most likely diagnosis?

1. Sigmoid volvulus
2. Toxic Megacolon
3. Acute pseudointestinal obstruction
4. Mesenteric Ischemia

Select the right answer, document about the disease. But at the same time discuss the diseases that you are ruling out ….why can’t be that other diagnosis

‘

This is the Patient of (c) Acute pseudointestinal Obstruction or Ogilvie Syndrome which is characterized by severe colonic distension in the absence of any mechanical obstruction.

As ACPO is caused by

• trauma,
• serious infections,
• cardiac diseases (eg, myocardial infarction, congestive heart failure),
• Recent surgery
• electrolyte imbalance, and
• severe hypothyroidism are among the more common causes

And we know the patient is known case of Hypothroidism.

Patients with Acute pseudointestinal Obstruction typically have obstructive symptoms that include nausea, vomiting, and abdominal pain. This differs from mechanical obstruction by the fact that nearly 40%-50% of patients continue to pass flatus. So We Ruled out Sigmoid Volvulus

No major differences are noted between the symptoms of patients with Acute pseudointestinal Obstruction and patients with ischemic bowel except for a higher incidence of fever among patients with the other conditions such as Toxic megacolon, Mesentric Ischaemia etc

And Temperature is not that High so we Ruled the Toxic Megacolon and Mesentric Ischaemia.

List of patients health Stats-

•Temperature of 98.9°F (37.16°C),

•Heart rate of 104 beats/min,

•Respiratory rate of 22 breaths/min,

•Blood pressure of 112/84 mm Hg, and

•SpO2 - 92%

• White blood cell count: 14,000 cells/μL (reference range, 4500-11,000 cells/μL)

• Hemoglobin level: 13.9 g/dL (reference range, 13.5-17.5 g/dL)

• Hematocrit concentration: 37% (reference range, 45%-52%)

• Platelet count: 306,000 cells/μL (reference range, 150,000-450,000 cells/μL)

• Sodium level: 135 mEq/L (reference range, 135-145 mEq/L)

• Potassium level: 3.5 mmol/L (reference range, 3.6-5.2 mmol/L)

• Chloride level: 107 mmol/L (reference range, 98-106 mmol/L) • Blood urea nitrogen (BUN) level: 43 g/dL (reference range, 7-20 mg/dL)

• Creatinine level: 1.51 mg/dL (reference range, 0.6-1.2 mg/dL) • Glucose level: 102 mg/dL (reference level, < 100 mg/dL)

• Aspartate aminotransferase level: 46 U/L (reference range, 10-40 U/L)

• Alanine aminotransferase level: 41 U/L (reference range, 7-56 U/L)

• Alkaline phosphatase level: 142 IU/L (reference range, 44-147 IU/L)

• Amylase level: 25 U/L (reference range, 23-85 U/L)

• Lipase level: 19 U/L (reference range, 0-160 U/L)

• Lactic acid level: 0.7 mmol/L (reference range, 0.5-1 mmol/L)

Answer 1

The correct answer is C. Pseudo intestinal Obstruction or Ogilvie Syndrome which is characterized by severe colonic distension in the absence of any mechanical obstruction.

As ACPO is caused by

• trauma,
• serious infections,
• cardiac diseases (eg, myocardial infarction, congestive heart failure),
• Recent surgery
• electrolyte imbalance, and
• severe hypothyroidism are among the more common causes

And we know the patient is known case of Hypothroidism.

Patients with Acute pseudointestinal Obstruction typically have obstructive symptoms that include nausea, vomiting, and abdominal pain. This differs from mechanical obstruction by the fact that nearly 40%-50% of patients continue to pass flatus. So We Ruled out Sigmoid Volvulus

No major differences are noted between the symptoms of patients with Acute pseudointestinal Obstruction and patients with ischemic bowel except for a higher incidence of fever among patients with the other conditions such as Toxic megacolon, Mesentric Ischaemia etc

And Temperature is not that High so we Ruled the Toxic Megacolon and Mesentric Ischaemia.

List of patients health Stats-

•Temperature of 98.9°F (37.16°C),

•Heart rate of 104 beats/min,

•Respiratory rate of 22 breaths/min,

•Blood pressure of 112/84 mm Hg, and

•SpO2 - 92%

• White blood cell count: 14,000 cells/μL (reference range, 4500-11,000 cells/μL)

• Hemoglobin level: 13.9 g/dL (reference range, 13.5-17.5 g/dL)

• Hematocrit concentration: 37% (reference range, 45%-52%)

• Platelet count: 306,000 cells/μL (reference range, 150,000-450,000 cells/μL)

• Sodium level: 135 mEq/L (reference range, 135-145 mEq/L)

• Potassium level: 3.5 mmol/L (reference range, 3.6-5.2 mmol/L)

• Chloride level: 107 mmol/L (reference range, 98-106 mmol/L) • Blood urea nitrogen (BUN) level: 43 g/dL (reference range, 7-20 mg/dL)

• Creatinine level: 1.51 mg/dL (reference range, 0.6-1.2 mg/dL) • Glucose level: 102 mg/dL (reference level, < 100 mg/dL)

• Aspartate aminotransferase level: 46 U/L (reference range, 10-40 U/L)

• Alanine aminotransferase level: 41 U/L (reference range, 7-56 U/L)

• Alkaline phosphatase level: 142 IU/L (reference range, 44-147 IU/L)

• Amylase level: 25 U/L (reference range, 23-85 U/L)

• Lipase level: 19 U/L (reference range, 0-160 U/L)

• Lactic acid level: 0.7 mmol/L (reference range, 0.5-1 mmol/L)

In Sigmoid volvulus, there's complete Obstruction of the intestines and the patient cannot even pass the flatus, hence it is ruled out.

In Toxic megacolon the systemic signs of fever,chills and breathlessness are more,also there are chances of septicemia which is not given here, hence ruled out.

In mesenteric ischemia the abdominal pain is sharp and severe in intensity, also the pain has post prandial increase,which is not given in the case, hence ruled out.