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• W1503838151 abstract "To the Editor: Constipation in an elderly patient may be a presenting symptom of an underlying etiology. If the symptoms are overlooked and are treated symptomatically, it may lead to potentially life-threatening complications. Nonocclusive ischemic injury of the colon usually involves the watershed areas such as splenic flexure and rectosigmoid junction when associated with atheromatous emboli or low-flow states. The following case is presented to emphasize the importance of antecedent ischemia events causing constipation in elderly patients. A 76-year-old man recently discharged from a rehabilitation facility presented to the emergency department complaining of constipation of 5 days duration and no passage of flatus for the previous 24 hours. He denied nausea, vomiting, or diarrhea. He had tried stool softeners and sodium phosphate enema without effect. On examination, the abdomen was minimally distended, soft, nontender without rebound or guarding. Bowel sounds were present. Rectal examination found no stool in the vault and was guaiac negative. His medical history was significant for hypertension, coronary artery disease, abdominal aortic aneurysm (AAA) repair 2 months before the current admission, and diverticulosis (diagnosed on routine colonoscopy 6 months prior). Cardiogenic shock and respiratory failure requiring inotropic support for 4 days and mechanical ventilation for 11 days had complicated the AAA repair. For presumed sepsis, he received ciprofloxacin and piperacillin/sulbactam. He had progressive abdominal distension, and a computed tomography (CT) scan on the 10th postoperative day showed a dilated and featureless colon (Figure 1). On the 12th postoperative day, he underwent colonoscopy and was found to have pseudomembranous colitis. He was started on metronidazole, and the other antibiotics were discontinued. He developed atrial fibrillation that was rate controlled with metoprolol and diltiazem. Anticoagulation with warfarin was initiated. Over the next several days, his diarrhea resolved, and his condition stabilized. He was transferred to a rehabilitation unit, and during his stay there, he underwent elective cardioversion. After 1 month he was discharged. Computed tomography scan of the abdomen revealing featureless transverse colon. In the emergency department, an abdominal obstructive series (Figure 2A) showed a dilated colon, followed by a CT scan that revealed a narrowed sigmoid colon with a rectosigmoid stricture causing large-bowel obstruction (Figure 2B). After admission, the patient underwent sigmoidoscopy, and a tight stricture in the rectosigmoid with an estimated diameter of less than 5 mm was seen 20 cm from the anal canal. There was intermittent passage of liquid stool and flatus. The patient was started on parenteral nutrition. Over the next 10 days, he had two unsuccessful attempts at dilatation to pass the scope through the tight stricture. Once after an attempt at dilatation, he developed septic shock and required vasopressor and mechanical ventilatory support. His condition improved, and 1 week later he underwent sigmoid resection. Histopathologic examination revealed areas of mucosal ulcerations, and the findings were not inconsistent with ischemia. Wound dehiscence and multiorgan failure complicated his postoperative hospital course, and he eventually died. A. Abdominal x-ray revealing dilated colon. B. Computed tomography scan of the abdomen showing rectosigmoid stricture. Rectosigmoid stricture can be a complication of vascular compromise, malignancy, radiation, inflammation, or infection. In this patient, ischemia from interruption of blood flow was the most likely etiology. Possibilities include hemodynamic compromise that occurred in the postoperative period or atheroembolic disease. In an individual with a history of diverticulosis, complications associated with this entity should be considered. Ischemic colitis generally involves the watershed areas at the splenic flexure and the rectosigmoid junction, which are at greatest risk for injury because the collateral blood flow is most vulnerable.1, 2 Elderly patients with atherosclerosis3 typically present with evidence of ischemic colitis after episodes of hypotension or low-flow states to the colon or during shock. The length of the involved segment of the colon depends on the cause of injury. Atheromatous emboli can cause damage to short segments, whereas nonocclusive injury usually involves much larger portions of the colon. Surgery, including AAA repairs, can result in episodes of colonic ischemia but may involve larger portions of colon. As seen in this patient, with cardiovascular compromise after AAA surgery, he might have had a vascular insult, seen as a featureless colon on CT scan (Figure 1), which might have resolved but left residual effect on the watershed rectosigmoid region, causing a stricture. This stricture in turn caused the patient to have constipation, causing him to come to the emergency department. In conclusion, the clinical presentation of elderly patients with constipation should be clinically correlated with their recent medical and surgical history to minimize the morbidity and mortality associated with this condition. Financial Disclosure: None. Author Contributions: Ravi K. Bobba: patient care, manuscript preparation, editing. Edward L. Arsura: manuscript preparation, editing. Mohammad Naseem: patient care, manuscript preparation, editing. Khalil A. Amir: manuscript preparation, editing. Sponsor's Role: None." @default.
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• W1503838151 date "2005-09-01" @default.
• W1503838151 modified "2023-09-23" @default.
• W1503838151 title "RECTOSIGMOID STRICTURE PROBABLY FROM ISCHEMIA PRESENTING AS CONSTIPATION IN AN ELDERLY PATIENT" @default.
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• W1503838151 doi "https://doi.org/10.1111/j.1532-5415.2005.53487_4.x" @default.
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