September 2014 Critical Care Case of the Month: Bad Case of Colic

Sherry Andrews MD

Eyad Almasri MD

Pulmonary and Critical Care

UCSF Fresno

Fresno, CA

History of Present Illness:

A 70 year old man with a past medical history of chronic kidney disease, bipolar disorder, benign prostatic hypertrophy, hypertension and diabetes presented to the emergency department with constipation associated with bloating for 15 days. He denies flatus. He tried over the counter laxatives (polyethylene glycol) with no relief. He has no recent history of colonoscopy or recent antibiotic use. He denies chills, diarrhea, dysuria, fever, hematochezia, hematuria, melena, nausea or vomiting. In the emergency department, he is tachypneic with a grossly distended abdomen.

Past Medical History:

• Diabetes
• Hypertension
• Chronic kidney disease
• Bipolar disorder
• Benign prostatic hypertrophy
• Hyperlipidemia

Past Surgical History:

• Cholecystectomy 2012

Medications:

• Aspirin 81 mg daily
• Furosemide 20 mg daily
• Quetiapine 300 daily
• Doxazosin- 4 mg daily
• Clonazepam 1 mg – twice daily as needed
• Simvastatin 20 mg – daily
• Pioglitazone 15 mg daily

Social History:

He is a retired farm laborer and worked in a cannery. He is married and has two adult children.

He was a former smoker and quit in 2010 He denies any alcohol or illicit drug use

Physical Exam:

• Vital signs – Temperature 37.2 °C, heart rate 84 beats/min, respiratory rate 18-24 breaths/min, blood pressure 121/83 mmHg, SpO2 94 % on 4 L NC 
• General – Average build, well-nourished, in mild distress
• HEENT – Unremarkable
• Neck - Supple, no jugular venous distention
• Chest – Decreased breath sounds right base more than left base
• Heart - Regular rate, normal S1/S2, no murmur
• Abdomen – hypoactive bowel sounds, soft, distended, non-tender to palpation but diffusely tympanic.
• Neurological - Appropriately moves all 4 extremities, CN II-XII grossly intact
• Extremities - No edema
• Skin - No rash or palpable nodules

Laboratory:

• CBC: WBC 6.4 X 10³ /μL, hemoglobin 15.3 g/dL, hematocrit 45%, Platelets 121,000 /μL.
• Chemistries: Na⁺ 141 mmol/L, K⁺ 4.5 mmol /L, Cl^- 105 mmol /L, CO₂ 25 mmol /L, blood urea nitrogen (BUN) 24 mg/dL, creatinine 1.2 mg/dL, glucose 95 mg/dL, calcium 9.9 mg/dL, albumin 4.2 g/dL, liver function tests within normal limits. hemoglobin A1C 5.1%. lactic acid 1.8 mmol/L
•  Coagulation: Prothrombin time (PT) 16.6 sec, international normalized ratio (INR) 1.3

Radiography:

A CT scan abdomen and pelvis was done and a representative coronal view is shown in Figure 1.

Panel 1. Coronal cut of computed Tomography (CT) of the abdomen and pelvis on admission.

Which of the following are characteristics of acute colonic pseudo-obstruction (Ogilvie’s syndrome)? (Click on the correct answer to proceed to the next panel)

1. Antibiotics and abnormal bacterial overgrowth are implicated in the pathogenesis
2. Immediate surgical decompression is required
3. It is a complication of inflammatory bowel disease
4. It occurs in the absence of an anatomic lesion that obstructs the flow of intestinal contents

Reference as: Andrews S, Almasri E. September 2014 critical care case of the month: bad case of colic. Southwest J Pulm Crit Care. 2014;9(3):151-9. doi: http://dx.doi.org/10.13175/swjpcc094-14 PDF