What is the recommended next step for a 68-year-old woman with severe abdominal pain, bloody diarrhea, and radiographic evidence of bowel wall thickening, who is currently receiving intravenous fluids, antibiotics, and medications for blood glucose management, and has a history of obesity, hypertension, and type 2 diabetes mellitus (T2DM) with retinopathy, and is taking lisinopril, hydrochlorothiazide, and metformin, presenting with fever, tachycardia, tachypnea, anemia, leukocytosis, and thrombocytosis?

From the Guidelines

I strongly recommend computed tomography angiography (CTA) for this 68-year-old woman. The patient's presentation strongly suggests ischemic colitis, evidenced by acute abdominal pain followed by bloody diarrhea, along with CT findings of bowel wall thickening, edema, and thumbprinting in the descending and transverse colon. Her risk factors include advanced age, hypertension, diabetes with retinopathy, obesity, and exposure to high temperatures which may have caused dehydration. The elevated white blood cell count, tachycardia, and fever indicate an inflammatory response.

Key Considerations

• CTA is the diagnostic study of choice for acute mesenteric ischemia (AMI) as it allows for the evaluation of mesenteric blood flow and identification of any vascular occlusion or stenosis causing bowel ischemia 1.
• The patient's CT findings are consistent with ischemic colitis, and CTA would provide crucial information about vascular status before considering more invasive approaches like laparotomy.
• Delay in diagnosis is a significant factor in high mortality rates, and every 6 hours of delay in diagnosis doubles mortality 1.

Diagnostic Approach

• CTA should be performed without delay in any patient with suspicion for AMI, as recommended by the World Society of Emergency Surgery 1.
• The procedure allows for both diagnosis and potential therapeutic intervention through vasodilator administration or endovascular treatment of occlusions.
• While continuing supportive care with IV fluids, antibiotics, and glucose management is important, CTA provides critical information about vascular status.

Potential Complications

• Bowel perforation, necrosis, or peritonitis would require a more invasive approach like laparotomy, but these signs are not evident in the current presentation.
• The patient's risk factors and clinical presentation suggest a high risk for complications, making prompt diagnosis and treatment essential.

Conclusion Not Applicable -

Instead, the following is a continuation of the thought process: Given the high-quality evidence from the World Society of Emergency Surgery 1, CTA is the most appropriate next step in the management of this patient, allowing for timely diagnosis and potential intervention to prevent further complications.

From the Research

Patient Condition

The patient is a 68-year-old woman with a history of obesity, hypertension, and type 2 diabetes mellitus, presenting with lower midline abdominal pain and bloody diarrhea after attending an outdoor wedding in high temperatures. Her current medications include lisinopril, hydrochlorothiazide, and metformin.

Diagnostic Findings

• CT scan with oral and intravenous contrast shows bowel wall thickening, edema, and thumbprinting in the descending colon and transverse colon.
• Laboratory studies reveal a hematocrit of 23, hemoglobin of 11.6, leukocyte count of 16.2, and platelet count of 574,000.
• The patient has a temperature of 38.7, pulse rate of 106, and respirations of 22.

Treatment Options

Based on the diagnostic findings, the patient's condition suggests ischemic colitis, which is supported by the study 2. The treatment for ischemic colitis is typically supportive, with intravenous fluids and bowel rest. Broad-spectrum antibiotics should be initiated, and surgical consultation should be obtained in cases of severe disease, pancolonic ischemia, or isolated right colonic ischemia.

Recommendation

Given the patient's condition and the findings, the recommended course of action is:

• Intravenous fluids and antibiotics to manage the patient's condition and prevent further complications.
• Surgical consultation to assess the need for potential surgical intervention, such as laparotomy, if the patient's condition worsens or does not improve with supportive care.
• No sedation is recommended at this time, as it may mask the patient's symptoms and make it difficult to assess their condition.
• Angiography may be considered if there is a concern for mesenteric ischemia or other vascular complications, but it is not the primary recommendation at this time.
• Laparotomy may be necessary if the patient's condition worsens or if there is evidence of peritonitis, hemodynamic instability, or failure of non-operative management, as suggested by the study 3.

Considerations

The patient's age, comorbidities, and current condition increase the risk of complications and mortality, as highlighted by the studies 4 and 5. Therefore, close monitoring and proactive management of the patient's condition are essential to improve outcomes.