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Rectal Pain

UnFiNiShEd CaSe CoMe BaCk LaTeR

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History of Present Illness:

A 72-year-old female with history of narcotic bowel and multiple prior abdominal surgeries presents to the ED for severe right lower abdominal pain and rectal pain over the past week.  She was actually at another ED 2 days ago for the same pain, but now it is worse.  She denies fevers, chills, nausea, vomiting, diarrhea, bleeding or melena, hematuria, dysuria or other complaints

Vital Signs & Physical Exam:

Vital signs are remarkable for a pulse of 103, BP 190/110 and RR of 24.    Physical exam is notable for moderate distress and diffuse lower abdominal tenderness without rebound.  Rectal exam shows a large stool ball

Initial Differential Diagnosis:

  • Pelvic abscess
  • Constipation
  • A bunch of other stuff
  • Syphilis, the great imitator

Initial Diagnostic Testing:

  • Labs: WBC = 12 with 77% PMN.  BMP normal
  • Imaging: See slice of CT scan below

QUESTIONS:

  1. What does the case image show?  
  2. What should you do next?  
  3. Want a 1-minute consult/tutorial on this case? 
  4. Want to know what happened with this patient?

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ANSWERS:

  1. What does the case image show?  It shows urinary bladder wall thickening and enhancement c/w cystitis, increased colorectal stool and thick-walled rectum c/w stercoral colitis and finally, trace pelvic free fluid.
  2. What should you do next?  Treat with laxatives, enemas and disimpaction.  Consult colorectal surgery.  Get a UA
  3. Want a 1-minute consult/tutorial on this case?  See yellow area from sample page below.
  4. Want to know what happened with this patient?  See case conclusion below tutorial page.

1-Minute EM Consult on the topic for this case from the Emergency Medicine 1-minute Consult Pocketbook

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CASE CONCLUSION: She was admitted.

CASE LESSONS:

  1. Always
  2. Never
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