A 26-year-old male with a history of cerebral palsy (CP) presented to the Emergency Department (ED) with the complaint of abdominal distension and constipation. The patient's mother was present and also the primary caregiver at home. The patient had a history of chronic intermittent constipation requiring weekly laxatives and fleets enemas. On this occasion, despite use of polyethylene glycol 3350 (an osmotic laxative), multiple enemas, and an attempt at manual fecal disimpaction by the mother, the patient had persistent constipation and discomfort. His vital signs were blood pressure: 148/85, heart rate: 150, respiratory rate: 20, and oxygenation saturation: 99% on room air, and he was afebrile. On exam, the patient had a decrease in mental status. His abdomen was markedly distended and rigid (Figure ). Bowel sounds were absent. Laboratory studies showed no overwhelming abnormalities, with a white blood cell count of 13,000, creatinine level of 0.7, and potassium level of 3.7. An acute abdominal series showed a significantly distended colon with a 26-cm estimated diameter (Figure ). CT of the abdomen showed a large amount of stool and air in the colon without evidence of a mechanical obstruction, bowel wall thickening, or signs of perforation (Figures , and ).
Photo demonstrating severe abdominal distention.
X-ray revealing severe colonic dilatation from the pseudo-obstruction with large stool collection.
Axial CT image of the pseudo-obstruction and severely dilated colon.
Coronal CT image of pseudo-obstruction and severely dilated colon that almost completely fills the view of the abdomen cavity.
Sagittal CT image of the pseudo-obstruction.
The patient was resuscitated in the ED with 2 l normal saline, and he was given intravenous antibiotics, piperacillin/tazobactam, to cover enteric bacteria for concern of impending bowel perforation and probable current microperforation. A nasogastric (NG) tube was placed. Gastroenterology and the general surgeon were immediately consulted. A gastrograffin enema was performed. No evidence of mechanical obstruction was visualized. As a precaution, the patient was admitted to the ICU for further management and care. The patient's white blood cell count rose to 26,000 on the second day. With NG tube decompression and multiple enemas, the patient eventually passed stool and gas. The colonic distention resolved without pharmacological, endoscopic, or surgical interventions. The patient did not develop worsening signs of sepsis or perforation, and was discharged in improved and stable condition.