Morning Report S a p n a P a t e l K u e h l M D F A C P S t. A g n e s H o s p i t a l, B a l t i m o r e M D
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1 Morning Report Sapna Patel Kuehl MD FACP St. Agnes Hospital, Baltimore MD
2 Chief complaint Found confused in bathtub
3 History of present illness 74 yo woman with PMHx of COPD, on home oxygen 2L presented with altered mental status and urinary incontinence hurt all over Did not recollect the event nor any premonitory symptoms No fecal incontinence or tongue bite Poor appetite, undefined weight loss
4 Past Medical History COPD on 2L oxygen Rheumatoid Arthritis Fibromyalgia Chronic pain syndrome? Hypothyroidism Choledocholithiasis Total hysterectomy Lumpectomy
5 Medications Hydroxychloroquine 200mg PO Q day Hydrocodone-acetaminophen mg PO Q4H PRN Often ran out of it early, going to ER/clinics Tiotroprium handihaler 1 capsule Q day Levothyroxine 25mcg PO Q day Allergy: Aspirin- rash
6 Additional History Widow,lived alone 2 sons, who checked in on her frequently; very involved in her care Former smoker, quit < 1 year ago Occasional EtOH consumption No illicit drug use Family history: non contributory ROS: NC
7 Physical exam Temperature Pulse rate RR BP Pulse Ox 97.6 F 110bpm 20/min 158/82 mmhg 97% (2L O2 NC) General: alert, anxious, restless, BMI Kg/m2 HEENT: edema and ecchymosis in the occipital and rt. temporal region, hair crusted with dry blood, PERRL, dry oral mucosa Respiratory: tachypneic, b/l decreased air entry Cardiovascular: tachycardia, no murmur/peripheral edema/ JVD Gastrointestinal: distended, soft, non-tender, NABS Musculoskeletal: joint deformities, tenderness in occipital region Neurologic: alert / oriented x 3, motor normal, non-focal exam Skin: ecchymosis of b/l knee and left elbow
8 Labs CBC normal, mildly elevated LFTs with no elevation in bili/ alk phos TSH normal URINE: yellow, hazy, ph 5, 1+ pro., no ketones, no infection Chest x-ray: no acute lung process
9 ED evaluation CT of head without contrast: no acute bleed or ischemia EKG: sinus tachycardia, no acute ST-T wave changes Cervical CT: mild degenerative disk changes; no acute fracture
10 Initial Management Syncope v.s. seizure workup Altered mental status-> resolved Acute Kidney Injury Anorexia Chronic Pain syndrome, opioid dependent COPD oxygen dependent Elevated LFTs, choledocholithiasis
11 Day 2 Acute diffuse abdominal pain One episode of large amount of coffee ground emesis NGT placed, GI evaluation BUN: 108 Creat: 2.3, Hgb unchanged
12 Bilateral hydronephrosis
13 CT Bilateral scan hydroureteronephrosis abdomen and pelvis
14
15
16 Obstructive uropathy with bilateral hydroureteronephrosis secondary to severe constipation with fecal impaction
17
18 Causes of AKI: Post-renal Prostatic hypertrophy - most common cause Renal calculi, clots, strictures Neurogenic bladder Retroperitoneal fibrosis Tumor: Cervical or urinary, bladder, colorectal
19 Obstructive Uropathy due to constipation Described in less than 50 cases 20 cases in adults First case in 1954
20 Iwata Y, Kunishi Y, Yoshie K. Obstuctive Uropathy caused by chronic constipation. Intern Med 54: , 2015 DOI: /internalmedicine Epub 2015 May 1. PMID:
21 Chronic Constipation 8 million annual visits Prevalence of 12-30% Women and elderly Combination of infrequent stools and defecatory difficulties
22 Causes of chronic constipation Neurogenic disorders Peripheral Diabetes mellitus Autonomic neuropathy Hirschsprung disease Chagas disease Intestinal pseudoobstruction Central Multiple sclerosis Spinal cord injury Parkinson disease Irritable bowel syndrome Drugs Non-neurogenic disorders Hypothyroidism Hypokalemia Anorexia nervosa Pregnancy Panhypopituitarism Systemic sclerosis Myotonic dystrophy Idiopathic constipation Normal colonic transit Slow transit constipation Dyssynergic defecation
23 Drugs causing constipation Analgesics Anticholinergics Antihistamines Antispasmodics Antidepressants Antipsychotics Cation-containing agents Iron supplements Aluminum (antacids, sucralfate) Barium Neurally active agents Opiates Antihypertensives Ganglionic blockers Vinca alkaloids Calcium channel blockers 5HT3 antagonists
24 Chronic Constipation Alarm symptoms: sudden changes in bowel habits blood in stool unexpected weight loss strong family hx of colon cancer Most GI societies recommend a CBC as screen for anemia Selected patients: TSH, Calcium, glucose
25 Fecal Impaction Inability to sense and respond to the presence of stool in the rectum. Common causes: Decreased mobility and lowered sensory perception Diagnosis Digital rectal examination (not necessarily hard) Can occur in the proximal rectum or sigmoid colon
26 Fecal Impaction Management Manual disimpaction Warm-water enema with mineral oil If the above measures fail: local anesthesia to relax anal canal and pelvic floor muscles abdominal massage colonoscope with a snare to fragment fecal material Impending perforation or ischemia -> surgery may be necessary
27 Take home points The prevalence of constipation in the older adults is as high as 24 to 50 percent. Address constipation in all patients, especially patients with diabetes, psychiatric disease, on medications that cause constipation. Chronic constipation causing obstructive uropathy is very rare. However, it should be considered as one of the possibilities of renal function impairment.
28 Thank you
29 January 12, 2016
30
31
32 Opioid Induced Constipation Naloxegol (Movantik) for Opioid-Induced Constipation.JAMA. 315(2): , January 12, 2016.DOI: /jama
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