Mark Crislip, MD

Disclosures

June 06, 2012

Clinical Presentation: Sudden Abdominal Pain

A 74-year-old woman presents with sudden onset of abdominal pain and bloody diarrhea.

History and Physical Examination

History. The patient fell ill 48 hours before admission. Initially, she experienced weakness, then developed nausea and had an episode of vomiting.

Within 24 hours, she was having fevers, rigors, high-volume bloody diarrhea with severe cramps, and bloating. She was admitted to the hospital for dehydration and acute gastroenteritis. After results of colonoscopy, she started treatment with prednisone.

History revealed the following:

  • Medical history: hypertension, gastroesophageal reflux disease, type 2 diabetes mellitus, hypothyroidism

  • Medications: proton-pump inhibitor, thiazide diuretic, thyroid replacement, oral hypoglycemic agent

  • Allergies: none

  • Habits: neither smokes or drinks alcohol

  • Pets: 2 indoor cats

  • Diet: regular, with a propensity for "natural" foods

  • Travel: 1 month ago, went to Mexico to visit Catholic shrines

  • Social: lives alone; minimal contact with the healthcare system

  • Immunizations: up to date

  • Sports/water exposure: consumes a "dollop" of holy water every day, from plastic jugs she filled in Mexico

  • Infectious disease exposure: nothing else of significance

Physical examination. The following were noted:

  • Vital signs: temperature, 102° F; pulse, 122 beats/min; respiratory rate, 12 breaths/min; blood pressure, 90/40 mm Hg (improving to 120/60 mm Hg after receipt of several liters of intravenous normal saline)

  • General: ill-appearing

  • HEENT: normal

  • Lungs: clear

  • Heart: normal

  • Abdomen: distended, and tender, with slight rebound

  • Extremities: normal

  • Skin: dry

Diagnostic Evaluation

Laboratory results. The following values were obtained:

  • WBC count: 3.5 × 103 cells/mm3

  • Hemoglobin level: 9.8 g/dL (was 11.5 g/dL 2 months ago)

  • Differential: 55% bands

  • Serum sodium level: 128 mEq/L

  • Creatinine level: 3.1 mg/dL

  • Bilirubin level: normal

  • Aminotransferase levels: normal

  • Stool: sheets of WBCs

Imaging. The following were noted:

  • Flat plate of abdomen: air-fluid levels and distention

  • CT: pancolitis with dilated, thick-walled bowel

Colonoscopy. Findings on colonoscopy are grossly consistent with acute ulcerative colitis. Results of biopsy are pending.

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