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Case Report
An 81-year-old woman with a history of dementia, diabetes mellitus, and chronic renal insufficiency presented to her primary nephrologist with a 1-week history of fatigue and low-grade temperatures. Her review of systems was also remarkable for recurring diarrhea over the last year that had resolved recently after receiving increasing doses of loperamide from her family, the exact amount unclear. She reported no changes in her fluid intake or urinary output. Her physical examination was remarkable for a distended abdomen. She was referred to the emergency department, where her abdomen was found to be further distended, and she became progressively tachypneic. A Foley catheter was placed, with immediate output of 500 mL of urine but no resolution of symptoms or distention. Laboratory studies revealed high blood urea nitrogen (133 mg/dL from her baseline of 106 mg/dL) and creatinine (2.5 mg/dL from her baseline of 2.2 mg/dL), bicarbonate of 12 mEq/L, an anion gap of 14 mEq/L, and a normal lactic acid of less than 0.3 mg/dL. An arterial blood gas revealed a pH of 7.08, partial pressure of carbon dioxide of 28 mm Hg, and partial pressure of oxygen of 81 mmHg. She was intubated, and emergent computed tomography (CT) of her abdomen and pelvis revealed marked dilation of the sigmoid colon and rectum with rectal impaction of stool, along with moderate bilateral hydronephrosis, thought to be caused by mass effect from the dilated sigmoid (Figure 1A). No obstructing calculus was seen. She was transferred to the medical intensive care unit, where she was started on an aggressive bowel regimen and manually disimpacted. Within 12 hours of disimpaction her electrolyte disturbance and renal function returned to baseline, and she was successfully extubated. On Day 4 of admission, follow-up CT demonstrated complete resolution of the sigmoid dilatation and bilateral hydronephrosis (Figure 1B).
(Enlarge Image)
Figure 1.
(A) Bowel imaging Day 1 (on admission): Marked dilation of the sigmoid colon and rectum with rectal impaction of stool, note moderate bilateral hydronephrosis due to mass effect from the dilated sigmoid (arrow). No obstructing calculus. (B) Bowel imaging Day 4 (after disimpaction): Interval resolution of the sigmoid dilation and bilateral hydronephrosis.
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