A 70-Year-Old Man With Deteriorating Mental Status and Pain

Gamal A. Bebars, MD, FRCS; Evelyn P. Bebars, MD, FPCR

Disclosures

October 23, 2018

Physical Examination and Workup

Upon physical examination, the patient is an obese (approximately 242.5 lb [110 kg]), elderly male, who is obtunded. He has a patent airway, bilateral rales, and diminished air entry into both lung bases, normal S1 and S2 heart sounds, pallor, poor capillary refill, and a weak, rapid radial pulse. His heart rate is 124 beats/min. The patient is febrile, with a temperature of 102°F (38.9°C). His blood pressure is 85/65 mm Hg, and his respiratory rate is 26 breaths/min.

The patient's abdomen is grossly distended and hyperresonant, particularly above the umbilicus. Bowel sounds are totally absent; digital rectal examination reveals hard stools in the rectum. The patient is resuscitated in the ED using an intravenous infusion of lactated Ringer solution. Orotracheal intubation is performed and mechanical ventilation maintained. Intravenous antibiotics are started and a surgical consultation ordered, and then the patient is transported to the intensive care unit.

Laboratory results reveal the following:

  • White blood cell count - 22,500 cells/mm3 (reference range, 4,000-11,000 cells/mm3), with 82% neutrophils (reference range, 40%-75%)

  • Serum hemoglobin level - 9.2 g/dL (reference range, 13.5-18 g/dL)

  • Hematocrit level - 27.5% (reference range, 40%-54%)

  • Serum alanine aminotransferase (ALT) level - 78 U/L (reference range, 5-40 U/L)

  • Serum bilirubin level - 2.3 mg/dL (reference range, 0.2-1.2 mg/dL)

  • Serum C-reactive protein level - 28 mg/dL (reference value, < 1.2 mg/dL)

  • Serum creatinine level - 4.8 mg/dL (reference range, 0.6-1.4 mg/dL)

  • Serum urea level - 79 mg/dL (reference range, 17-50 mg/dL)

A plain chest x-ray shows a large air-filled bowel loop in the left hemithorax, with displacement of the mediastinum towards the right side (Figure 1). A supine abdominal x-ray reveals distended small and large bowel loops (Figure 2). A CT scan of the abdomen using both oral and intravenous contrast shows eventration of the left hemidiaphragm and a small right inguinal hernia with a gas shadow amongst its contents (Figure 3).

Figure 1.

Figure 2.

Figure 3.

The CT scan also demonstrates thickening of the bowel wall and omentum in addition to multiple abscesses between the bowel loops and within the pelvis. The appendix cannot be visualized in the right iliac fossa, and mesenteric vascular occlusion is not evident.

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