Constipation is one of the most common functional gastrointestinal disorders and affects 20% of the general population. Irritable bowel syndrome (IBS) is a functional disorder of the gastrointestinal tract that affects the large intestine and is characterized by chronic abdominal pain and altered bowel habits. We report a case of a 35-year-old African American man with a past medical history of IBS who presented to the clinic with a chief complaint of abdominal pain and bloody diarrhea for 1 week. The patient stated that he used a colon-cleansing agent because of persistent constipation. Computed tomography scan of the patient’s abdomen and pelvis with contrast was performed which showed diffuse contiguous segmental mural thickening and nodularity seen along the distal transverse, descending, and sigmoid colon. Colonoscopy showed moderate diffuse inflammation characterized by altered vascularity, erythema, and granularity from the rectum to the descending colon, and localized mild inflammation characterized by erythema was found at the ileocecal valve. The patient’s clinical condition improved with symptomatic management over 10 days. Patients with IBS should be advised to restrain from using a colon-cleansing agent without advice from their primary doctor as it can lead to various complications.
INTRODUCTION: Gastroparesis in diabetics can be worsened by hyperglycemia. Acute elevations in blood glucose suppress the frequency and contraction amplitude of antral pressure waves while stimulating phasic pyloric pressure waves, which can result in Acute Gastric Dilatation (AGD). Though an unusual occurrence, it requires a high degree of suspicion to avoid its rare but life-threatening complications. We present our experience of two patients with AGD. CASE DESCRIPTION/METHODS: Case 1: A 30-year-old male presented to the ER with nausea, vomiting and abdominal pain. His comorbidities included type 1 diabetes and end-stage renal disease. On examination, his abdomen was notably distended and bowel sounds were sluggish. No guarding or rigidity was appreciated. He was hypotensive (76/49 mmHg) and hypoxic. Lab values were significant for blood glucose of 1155 mg/dL and a pH of 6.97. He was emergently intubated and started on IV insulin and Epinephrine. An abdominal plain film x-ray showed acute gaseous distention of the stomach. An NG tube was passed which drained 500cc of brownish gastric content. A repeat x-ray 4 hrs later revealed resolution of gastric dilatation which was confirmed by CT-abdomen. Patient's abdominal symptoms improved thereafter and he made a full recovery in time. Case 2: 59-year-old male was brought to the ER with an altered mental status. As per EMS, he had “very high” blood sugar levels. His comorbidities included diabetes mellitus and chronic hepatitis C. His abdomen was distended with decreased bowels sounds. His vital signs were stable. Lab values were significant for hyperglycemia (649 mg/dL), and a blood pH of 7.29. He underwent an abdominal x-ray which showed marked distention of the stomach. A follow-up CT abdomen confirmed the finding, with no mechanical cause of obstruction identified. He was started on IV Insulin, IV antibiotics and was planned for endoscopic workup, however, his conditioned rapidly deteriorated and he required pressors with mechanical ventilation. The patient eventually suffered a cardiac arrest and was unable to be revived. DISCUSSION: AGD presents with nausea, vomiting, succussion splash, and abdominal distension. Acute hyperglycemia in uncontrolled diabetics is the precipitating factor. If intragastric pressures exceed 20 cmH20 (lower limit of gastric venous pressure), it can cause mucosal ischemia and necrosis. This may be followed by perforation, which has a high mortality rate. Emergency decompression with NG tube seems to be the treatment of choice.
Colonoscopy is a commonly performed low-risk gastrointestinal procedure that may rarely result in a serious complication. Patients presenting with abdominal pain and fever after colonoscopy may have acute cholecystitis. The underlying mechanisms are unclear. Such patients usually present within 72 hours of the procedure. Treatment includes intravenous antibiotics and cholecystectomy. We present our experience of two such cases; a 56-year-old man and a 21-year-old man, both of whom developed acute calculus cholecystitis within 48 hours after a routine colonoscopy. Their symptoms resolved after cholecystectomy.
Spontaneous splenic rupture is an uncommon but life threatening acute emergency. Up to one half cases of Atraumatic splenic rupture (ASR) are preceded by splenomegaly. Hematological malignancies can present with splenomegaly and have clinical features of left upper quadrant (LUQ) pain and fullness. Abdominal pain is one of the commonest reasons for consulting Gastroenterology in the in-patient setting. We present a case of a patient who developed symptoms due to ASR which was not evident on initial imaging. While there are multiple causes of ASR, neoplastic etiologies account for about a third of these cases. Hairy Cell Leukemia (HCL) is a rare lymphoid neoplasm which often presents with nausea, vomiting, and LUQ pain. Splenomegaly is a common manifestation of this disease, although ASR occurs much less frequently. This report highlights a case of a 64-year-old woman with known comorbidities of hypertension and diabetes, who presented with persistent nausea, vomiting and epigastric pain, for one week. Prior to presentation, she had complained of intermittent abdominal pain for 16 months. A computerized tomography (CT) scan of abdomen done a year earlier had revealed a nonspecific wedgeshaped, low attenuating lesion in the spleen- suspicious for a splenic infarct. On examination, she was hemodynamically stable, with mild discomfort in the LUQ and palpable splenomegaly which was confirmed by imaging studies. The patient was thought to have gastroparesis secondary to uncontrolled diabetes mellitus, and was being treated conservatively. Patient was then noted to have a significant drop in Hematocrit without signs of active gastrointestinal bleeding. Her abdomen became distended with moderate LUQ tenderness. A repeat CT scan of abdomen showed evidence of intraperitoneal hemorrhage. The patient underwent emergent angiography and a bleeding splenic vessel was identified and embolized. She underwent an open splenectomy for ASR. A 6 cm laceration was found on the lower pole of the spleen. Pathology of the specimen unexpectedly returned positive for HCL. Patients with splenomegaly often present with symptoms of nausea, vomiting, and minimal LUQ tenderness. Careful clinical evaluation and urgent investigations should be undertaken in these patients as they may develop serious complications. ASR is an important and life threatening complication which may develop acutely or insidiously and should be monitored for in any patient with splenomegaly of unknown cause.Figure 1Figure 2
Colitis is a chronic gastrointestinal system disease characterized by inflammation of the inner lining of the colon. Infectious colitis is one of the most common causes of colitis and is associated with significant mortality and morbidity. One of the rare causes of colitis includes vancomycin-resistant <i>Enterococcus faecium</i> (VRE). Lately, the prevalence of VRE has significantly increased in hospitals. We present a case of a 32-year-old American man who was initially admitted because of bilateral lower extremity weakness. The hospital course was complicated, with acute hypoxic respiratory failure secondary to pneumonia. The patient was intubated and was started on broad-spectrum antibiotics. Later on, the patient had severe diarrhea and was found to have clostridium difficile infection. Patient symptoms persisted despite completing the course of antibiotics. Colonoscopy was performed, and the patient was found to have a diffuse area of severely altered vascular, congested, erythematous, friable with contact bleeding, hemorrhagic, inflamed, nodular, and ulcerated mucosa in the sigmoid colon, in the descending colon, and the transverse colon. A biopsy was sent, and the patient was found to be growing VRE. Currently, there is no effective treatment available for VRE. Hospitals need to have an active surveillance program to identify these patients so that the infection does not spread to other patients.
