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Septic Shock Following an Ulcerative Colitis Flare

Case Editor - Kamyar Afshar

Reviewed By Critical Care Assembly

Submitted by

Felipe Teran

Pulmonary Research Laboratory, Regions Hospital, St Paul, Minnesota, USA

Facultad de Medicina, Clínica Alemana – Universidad del Desarrollo, Santiago, Chile

Bruce Bennett, MD

Department of Surgery, HealthPartners Medical Group, University of Minnesota, Minneapolis, USA

David J Dries, MD

Department of Surgery, HealthPartners Medical Group, University of Minnesota, Minneapolis, USA

Pulmonary Research Laboratory, Regions Hospital, St Paul, Minnesota, USA

Submit your comments to the author(s).

History

A 27-year-old male, with history of ulcerative colitis (UC) presented to the emergency room with a 10-day history of malaise, joint pain, diffuse abdominal pain, nausea, vomiting and bloody diarrhea.  He denied shortness of breath, chest pain and had no other complaints.

Past medical history: UC, treated with azathioprine; schizophrenia
Past surgical history: None
Medications: Aripiprazole, Azathioprine, Citalopram, Clonazepam, Fenofibrate, Mesalamine, Multivitamin, Simvastatin, Valproic acid

Physical Exam

Vital Signs:  BP: 106/57 mm Hg,  Pulse: 100/min, Temp: 103 °F (39.4 °C) (Oral), SpO2 94%  on room air

Notable findings on exam included dry mucous membranes, clear lungs, normal cardiac exam. Abdominal exam revealed the presence of bowel sounds and a soft abdomen with tenderness to palpation in both lower quadrants without rebound or guarding.

Lab

WBC: 15,200 /cubic millimeter
Hb: 11.8 g/dl
Hct: 34.9%
Plts: 318,000/cubic millimeter

Sodium: 134 mmol/L
Potassium: 4.0 mmol/L
Chloride: 101 mmol/L
CO2: 22 mmol/L
BUN 13 mg/dL
Creatinine: 1.4 mg/dl
Glucose: 97 mg/dl

ESR 28 mm/hr
C-reactive protein 11.2 mg/dl

Figures

Chest radiograph (Figure 1) showed no free air under the diaphragm and was otherwise unremarkable. CT abd/pelvis was obtained, showing diffuse thickening of the colon from the cecum to the rectosigmoid junction (Figure 2). He then underwent flexible sigmoidoscopy, which revealed friable, congested colonic mucosa. He was started on piperacillin/tazobactam and metronidazole empirically and was admitted to the medicine service with the diagnosis of an ongoing UC flare and likely abdominal sepsis.

Figure 1. Portable chest radiograph at time of admission

Figure 2. Non-contrast CT of abdomen and pelvis showing diffuse colonic thickening, consistent with UC flare.

Figure 3. Chest radiograph at time of SICU admission showing diffuse bilateral infiltrates and mild vascular congestion

Question 1

This patient has colonic changes and a history of UC. What is an indication for urgent or emergent surgical management?

References

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