What is the cause of acute abdominal distension and desaturation in a patient with a history of Clostridioides difficile (C. diff) colonization, currently saturating at 85% on 4 liters of oxygen, with engorged abdominal vessels, loud bowel sounds, and recent bowel movement, despite denying any pain?

From the Guidelines

The patient's management should prioritize relieving abdominal distension to improve respiratory function, with a focus on maintaining oxygen saturation above 84%, repeating flatus tube placement, and performing gastric decompression to reduce pressure, as these interventions are crucial in preventing further respiratory compromise and potential morbidity and mortality. The patient is experiencing abdominal distension causing respiratory compromise with oxygen saturation of 85% on 4L oxygen. Despite the distension, the abdomen is soft with active bowel sounds and no reported pain. The patient has engorged abdominal vessels and has received standard bowel care including flatus tube placement and macrogol, with a large bowel movement this morning. The abdominal girth of 115cm is near baseline.

Key considerations in the management of this patient include:

• Maintaining oxygen therapy to keep saturation above 84% to prevent hypoxia and its consequences on organ function 1
• Repeating flatus tube placement for gas decompression and performing gastric decompression to reduce pressure, which can help alleviate abdominal distension and improve respiratory mechanics
• Positioning the patient on their left side to optimize ventilation and reduce diaphragmatic compression, which can help improve lung expansion and gas exchange
• Obtaining an abdominal x-ray to assess for obstruction or ileus, which can guide further management and identify potential complications

Given the patient's history of C. difficile colonization and recent treatment for a similar episode in February, a stool sample should be collected to evaluate for C. difficile infection recurrence, though this requires careful interpretation in a colonized patient, as the presence of the toxin does not necessarily indicate active infection 1. Medication review is important to identify any contributing factors to the distension, such as anticholinergics or opioids that could be adjusted or discontinued, as these can affect bowel motility and contribute to distension.

It is also essential to consider the patient's overall clinical context, including their history of C. difficile colonization, recent antibiotic use, and current symptoms, to guide management decisions and prevent potential complications, such as severe CDI or respiratory failure, which can significantly impact morbidity, mortality, and quality of life 1.

From the Research

Assessment and Diagnosis

• The patient presents with increased abdominal distension and desaturation, with a saturation level of 85% on 4L oxygen 2, 3.
• The abdomen is distended but soft and non-tender, with engorged vessels visible on the abdomen 4.
• Bowel sounds are heard throughout, loud and very active, and the patient has received all charted bowel care, including a flatus tube and macrogol sachets 5.
• The patient's abdominal girth measured 115cm, which is close to their baseline, and they have a history of similar abdominal distension leading to splinting and affecting ventilation 6.

Potential Causes and Treatment Options

• Abdominal bloating and distension can be caused by various factors, including food intolerances, previous infections, disordered visceral sensation, delayed intestinal transit, or abnormal viscero-somatic reflux 2.
• Treatment options may include dietary changes, probiotics, antibiotics, prokinetic agents, antispasmodics, neuromodulators, and biofeedback 3.
• The patient's history of C. diff colonization and previous treatment for a flare-up may be relevant to their current symptoms 4.
• The plan to discuss with Dr. Byrne, request an abdominal x-ray, repeat flatus tube and gastric decompression, review medications, and administer oxygen to maintain saturation levels is appropriate given the patient's symptoms and history 5, 6.

Diagnostic Evaluation

• The use of abdominal x-ray and other diagnostic tests may help to identify the underlying cause of the patient's abdominal distension and guide treatment 2, 3.
• The patient's symptoms and physical examination findings, including the presence of bowel sounds and abdominal distension, should be taken into account when interpreting diagnostic test results 4, 5.
• The patient's history and physical examination findings should be considered in the context of their individual characteristics and presentation to establish an effective personalized evaluation and treatment plan 6.