What's Your Diagnosis? Constipation in the ED

Welcome to this month’s What’s Your Diagnosis Challenge!

But before we begin, check to see if you got the previous case on Emergency Department Management of Patients With Right Heart Failure correct.

Case Presentation: Emergency Department Evaluation and Management of Constipation

An 85-year-old woman with altered mental status is brought in by ambulance from a nursing home…

The patient has a history of diabetes, stroke, and mild dementia. The paramedic transporting her said the nursing home staff said she is usually alert and oriented to person and place, but today she is lethargic and barely talking. She hasn’t had a bowel movement in 5 days, even after getting an enema yesterday.
On examination, she is tachycardic, with a nontender but mildly distended abdomen. Her vital signs are: temperature, 37.3°C; heart rate, 114 beats/min; blood pressure, 104/58 mm Hg; and oxygen saturation, 94% on room air.
As you begin the workup, you wonder whether an episode of simple constipation could make someone this sick…

Case Conclusion

Your elderly nursing home patient certainly seemed sick. Given her history of constipation, you performed a digital rectal examination and felt a hard mass of stool in the rectum. Because you were concerned that the fecal impaction could have led to stercoral colitis, you ordered a CT scan, which showed inflammation of the colon wall and fat stranding at the rectosigmoid junction, but no frank perforation. Her laboratory studies showed an elevated WBC count, and recognizing the potential risk for sepsis, you initiated ceftriaxone and metronidazole and consulted surgery, who recommended disimpaction and admission to the hospital for serial abdominal examinations, and to follow up her blood cultures.