Sunday, September 2, 2012

The stubborn ileus

Almost a year ago, during my last rotation as a resident I had to do another month of night-shift. How wonderful is to work nights! Fortunately you can always find a cool case. And I found one.

Just finished admitting a young man who took too many shroom  and I got a call regarding an existing patient. An 18 yo W, the nurse told me, with severe constipation and abdominal pain needs more Miralax. That was a bit weird, so I asked few more questions. The patient had no past medical history. Already had a CT of the abdomen (equivalent dose of radiation of 300-500 chest xrays) that showed nothing abnormal. Labs unremarkable (lytes, pregnancy screening test). She had been diagnoses with ileus and started on industrial doses of laxatives. An enema proved unsuccessful.

Before I give her more Miralax, I decided to interview and examine the patient. I found her in bed, laying in fetal position. Well, it started about a week ago, with diffuse abdominal pain, followed by constipation, followed by inability to pass flatus. Then I turn on the examination lights (during my internship I did not want to bother a patient by turning the bright lights on and...missed something big). Started the exam by looking at her hands (cool internists always examine the nails, palms etc), followed by the rest of the body. Her legs had some purple non blanching petechiae.

 Non blanching petechiae could be vasculitis. And abdominal pain with vasculitis in a young patient are very likely Henoch-Schonlein purpura. Her UA had microscopic hematuria, platelets and WBCs were normal. So probably not HUS, ITP, leukemia. Well, it seems that in some cases, H-S syndrome can manifest with ileus.

I scribbled a brief note in the chart (that I don't plan to give more Miralax to treat H-S induced ileus) and left. Two specialists and three days later, the young lady is diagnosed with H-S purpura and started on a brief course of steroids. Her bowel function returns magically.

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