Clinical Vignettes/Case Reports-Small Intestine.

Abstract

The clinical spectrum of ischemic bowel disease ranges from mild and transient injury, to bowel perforation, peritonitis and septic shock in severe cases. Clinical and radiologic findings are non-specific and seen in other gastrointestinal (GI) conditions such as infectious and inflammatory colitis, creating a diagnosis dilemma. A non-GI pathology mimicking severe ischemic bowel is even more clinically challenging. We present the unique case of a patient with features suggestive of severe ischemic bowel, who was found to have bladder necrosis during surgery. A 57 year old female with risk factors for ischemic bowel including hypertension, dyslipidemia, diabetes mellitus and End-Stage Renal Disease on hemodialysis was found unresponsive with a Glasgow Coma Scale of 3 and subsequently intubated. Chart review revealed treatment of Escherichia coli (E.coli) cystitis with bladder wall thickening on imaging (Figure 1) one year prior. On admission, her temperature was 95.5F, heart rate 102 beats per minute and blood pressure 76/55 mmHg. The rest of her physical examination was otherwise unremarkable. Laboratory findings were notable for elevated white blood count (WBC - 15.2K/mcl), increased serum lactic acid levels (4.5 mmol/l), elevated serum procalcitonin to 112.5 ng/ml and E.coli bacteremia. Abdominopelvic CT scan showed small and large bowel thickening without evidence of obstruction or perforation (Figure 2), thickening and irregularity of the bladder wall with outpouchings (Figure 3), and mild ascites. She was admitted to the Intensive care unit (ICU) for treatment of septic shock from presumed ischemic bowel and E.coli bacteremia. By day 2 of ICU admission, her clinical condition deteriorated as evidenced by persistent hypotension, worsening leukocytosis (WBC - 33.1K/mcl) and severe lactic acidosis (lactic acid - 5.2mmol/l). She had urgent exploratory laparotomy which revealed necrotic bladder. There was no evidence of bowel ischemia as initially suspected. She had partial cystectomy and pathologic analysis of resected bladder tissue confirmed necrosis without malignancy. Our patient had cystitis, likely chronic, from E.coli infection complicated by bladder necrosis and septic shock. Interestingly, her presentation on admission mimicked severe E.coli - associated bowel ischemia. This case demonstrates that even in the presence of strong risk factors for ischemic bowel disease, clinicians should always consider other potential life threatening conditions.FigureFigureFigure