Chief Complaint

M.H. is a 71 year old female who presents to the ED with complaints of abdominal pain and distention x3 days.

History elements

• Constant, dull pain.
• 10/10 in severity
• Diffuse pain
• No radiation
• Pain began suddenly
• Standing improves the pain.
• Moving, sitting and lying down exacerbates the pain.
• Has not tried any medications
• Abdomen looks like she is “9 months pregnant.”
• Had 1 episode of non-bloody, non-bilious vomiting after dinner last night.
• Was able to keep water down this morning.
• Has not tried to eat or drink anything other than water since dinner last night.
• Last bowel movement was yesterday morning. It was soft in texture, no melena or hematochezia. No recent changes in bowel habits (i.e. constipation or diarrhea).
• No fever, chills
• No weight loss, fatigue
• No history of abdominal surgeries
• Has never gotten a colonoscopy
• No changes in diet habits
• Does not smoke or drink alcohol
• No recent travel
• No Pmhx
• No significant family history
• Retired- was previously an architect who worked from home.

Physical Exam

General:

• Well developed, well-nourished female in some discomfort, unable to find a comfortable position lying down. Appears stated age of 71. Neatly groomed, alert and oriented x3.

Vital signs:

• P- 86
• BP- 96/68
• R- 19
• T- 97.7

Skin:

• Diffuse mild jaundice. Decreased skin turgor.

Mouth:

• Dry, pale mucosa. No cyanosis. No masses, lesions, leukoplakia.

Thorax and Lungs:

• Clear to auscultation and percussion bilaterally. No adventitious sounds.

Cardiac Exam:

• Regular rate and rhythm. S1 and S2 are distinct with no murmurs, S3 or S4. No splitting of S2 or friction rubs appreciated.  

Abdomen:

• Severely distended and hard with no scars, striae or pulsations noted. No bowel sounds appreciated in any quadrants. Mildly tender to palpation with no guarding or rebound noted. No CVA tenderness appreciated.

Differential Diagnosis

• Volvulus
  • This pt has multiple findings consistent with this diagnosis. Volvulus is the twisting of the intestine on itself. It presents as sudden onset of abdominal pain, distention, nausea, vomiting and abdominal tenderness. These are all present in this patient. Additionally, the patient had no bowel sounds, a common finding in volvulus. A risk factor for volvulus is being over the age of 65, as this pt is.
• Small bowel obstruction
  • This pt presents with abdominal pain and distention, common finding with small bowel obstruction. Additionally, the nausea and vomiting suggests this as the diagnosis. Similar to volvulus, being over 65 is a risk factor. However, the greatest risk factor is prior abdominal surgeries, which is not present in this patient. This is why I chose to include this as the second differential.
• Pancreatitis
  • Pancreatitis does also present with abdominal pain which is what made me think of this as a differential. Additionally, in later stages it can cause abdominal distention and jaundice. Pancreatitis can also cause nausea and vomiting. This diagnosis is less likely than the above 2 for a few reasons. Firstly, the pain typically radiates to the back which is not a feature in this patient. Also, this patient does not have fever, a typical sign with pancreatitis. Also the biggest cause of pancreatitis is gallstones (which the pt does not have any history of) and alcohol consumption (which this patient denies).
• Colorectal cancer
  • Colorectal cancer is a cause of intestinal obstruction that is typically diagnosed in older adults and therefore this pt’s age made me think of this diagnosis. Additionally, later in the course of the disease there may be abdominal pain and distention, due to the obstruction from the tumor. Also this patient denied having any screenings done, including colonoscopy. This diagnosis is lowest on my list because of the acute onset this patient experienced, which is not usual for colorectal cancer. She also denied changes to bowel habits which is a typical symptom of colorectal cancer. 

Tests

• CBC with dif.
  • RBC 3.68; Hgb 8.3; Hct 28.3; MCV 76.9
• Type and screen
  • A positive
• Coag studies
  • aPTT= 27 (reference= 25.1-36.5 seconds)
  • PT= 14.1 (reference= 9.4-12.5 seconds)
  • INR= 1.2 (reference= 0.9-1.1 ratio)
• CMP
  • Sodium 134; creatinine 0.5; glucose 148

• Lipase
  • 29 (reference- 13-60 U/L)
• Bedside ultrasound
  • No free fluid noted
• Bedside chest and abdominal x-ray
  • Markedly dilated air-filled upper abdominal bowel loops consistent with obstruction. There is a 265 mm x 164 mm mid-abdominal distended viscus filled with ingested material or bowel contents. It may be the stomach or a closed loop obstruction of the bowel.
• CT abdomen/pelvis with contrast
  • There are massively dilated air-filled bowel loops proximal to a massively distended stool-filled cecal volvulus. There is a large quantity of free intraperitoneal air.

Diagnosis

• Cecal volvulus with perforation

Treatment

• Perforation
  • 4.5 g piperacillin-tazobactam in 100 mL D5W Q6H
• Pain control
  • IV acetaminophen 1,000 mg
  • IV ketorolac injection 15 mg

• Antiemetic
  • IV ondansetron injection 4 mg
• Dehydration
  • IV infusion normal saline 1,000 mL
• Perforated cecal volvulus
  • Surgical consult for likely surgical intervention
  • NPO

Patient education

• Educate regarding what cecal volvulus is and the necessity of treatment, in this case surgery, due to high mortality without it.
• Encourage adequate water intake and using fiber/laxatives, explaining that constipation is a risk factor for cecal volvulus.
• Educate regarding hospitalization post-op, length of stay depends on specific surgery done and individual health.
• Return precautions- severe abdominal pain, fever, persistent vomiting, or signs of infection at the surgical site.
• Adopting a healthy lifestyle, including a balanced diet, regular exercise, and stress management, can support your overall well-being and recovery.