Endgames Picture Quiz

A complicated case of diarrhoea

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g2172 (Published 20 March 2014) Cite this as: BMJ 2014;348:g2172
  1. S Vandermolen, foundation year 1 trainee1,
  2. K Ewins, specialist registrar in medicine for the elderly1,
  3. S Perera, consultant radiologist2,
  4. J Wright, consultant general surgeon3,
  5. F Huwez, consultant medicine for the elderly physician1
  1. 1Department of Medicine for Elderly, Southend University Hospital, Southend SS0 0RY, UK
  2. 2Department of Radiology, Southend University Hospital, Southend, UK
  3. 3Department of Surgery, Southend University Hospital, Southend, UK
  1. Correspondence to: S Vandermolen s.vandermolen{at}southend.nhs.uk

An 82 year old man presented with a six day history of watery diarrhoea, vomiting, abdominal cramps, and confusion. He had a history of hypertension, gout, and prostate cancer, which was well controlled on hormonal therapy. He was independent and lived alone. He had not travelled or used antibiotics within the past two months.

On examination he appeared dehydrated, but was haemodynamically stable and afebrile. His abdomen was soft and non-tender, with normal bowel sounds. He had some erythema around the anus. The rectum was empty on digital examination.

Initial investigations showed a raised C reactive protein (178 mg/L, reference range 0-8; 1 mg/dL=9.52 nmol/L) and acute kidney injury (creatinine 125 µmol/L, 60-130; 1 µmol/L=0.01 mg/dL; urea 16.6 mmol/L, 2.3-6.7; 1 mmol/L=2.8 mg/dL). He was also noted to be hypokalaemic (potassium 3.0 mmol/L, 3.5-5.3). A plain abdominal radiograph was normal. Stool was negative for Clostridium difficile toxin but stool culture grew Campylobacter jejuni.

He was managed supportively with fluid resuscitation and received oral erythromycin 250 mg four times daily for five days. Diarrhoea became less frequent, but he remained unwell with persistent abdominal pain, persistently raised inflammatory markers, and renal dysfunction. He developed a palpable mass in the left iliac fossa. Abdominal computed tomography (figure) showed numerous outpouchings of the colon (arrow 1), with fatty stranding (arrow 2), which suggested acute inflammation. An irregular fluid collection containing an air bubble was also seen along the sigmoid descending junction (arrow 3).

Abdominal computed tomogram showing numerous outpouchings of the colon (arrow 1), with fatty stranding (arrow 2), and an irregular fluid collection containing an air bubble along the sigmoid descending junction (arrow 3)

Questions

  • 1. On the basis of the patient’s history and radiological findings, what is the likely underlying cause?

  • 2. What are the complications of this condition and …

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