A 20-year old woman was admitted acutely under the care of the gastroenterologists with a 4 day history of central abdominal pain of moderate severity associated with nausea and vomiting. For the previous 6 months she had experienced mild non-specific chronic lower abdominal pain, which had been labelled as non-organic pain.
Her past medical history was complex. She had neuronal intestinal dysplasia as a baby which manifested as a pseudo-obstruction. Consequently she required a right iliac fossa end-ileostomy which was fashioned at the age of 11 months. Her colon had been left in situ. There was a family history of neuronal intestinal dysplasia. Her twin sister and brother had also had an end-ileostomy fashioned at a similar age.
She had longstanding psychological problems including fluctuating depression, obsessive compulsive disorder, and apparent psychosomatic disorder. In addition, she was wheelchair bound secondary to congenital spastic paraparesis. She suffered from recurrent urinary tract infections and had ongoing episodes of high stoma output.
For many years she had direct access to the medical gastroenterology ward for parenteral rehydration in case of high stoma output causing dehydration. On this occasion she was admitted to the gastroenterology ward for further management in view of what was thought to be recurrent non-organic symptoms.
On admission, she was apyrexial and haemodynamically normal. There were no signs of peritonitis, and a digital rectal examination was normal. Blood investigations and plain abdominal imaging on admission were unremarkable. A provisional diagnosis of a psychosomatic abdominal pain was made.
After 4 days the patient was transferred to the psychiatric ward as she was refusing to eat or allow the phlebotomists to take blood for routine investigations. Within 24 h of transfer she suffered a cardiac arrest. Attempts at cardiopulmonary resuscitation were eventually successful in restoring a cardiac output. She required intubation and ventilation and was transferred to the intensive care unit (ICU).
She was noted to be profoundly hypokalaemic with a K+ of 1.8 mmol/l. It was presumed that self induced vomiting had caused her hypokalaemia and this in turn had triggered ventricular fibrillation. After 24 h she was noted to have an increasing serum lactate that reached 17 mmol/l. She required increasing inotropic support and so a surgical opinion was sought.