MedStar Georgetown University Hospital Washington, DC
Award: Presidential Poster Award
Tenzin Choden, MD, Ilan Vavilin, MD, Thomas Loughney, MD; MedStar Georgetown University Hospital, Washington, DC
Introduction: Significant delays in presentation for ischemic strokes and myocardial infarctions have been reported due to patients’ hesitation to seek care for fear of contracting COVID (Corona Virus Disease) in a health care setting, or inability to access an in-person appointment. This may occur with complicated gastrointestinal disease as well. Here we present a case of a mortality resulting from sigmoid volvulus after a delay in seeking care due to COVID.
Methods: A 79-year-old Caucasian man with past medical history of Parkinson’s disease, pulmonary emboli on anticoagulation, and chronic constipation presented to the Emergency Room with 13 days of abdominal distention and pressure. He had no bowel movements for over 5 days with no flatus in 24 hours. Outpatient clinics limited face to face visits due to COVID 19 pandemic, and video visits were not yet available. His wife had called his primary care clinic during day 4, 9, 11, and 12 of his symptoms of constipation (Figure 1) and received recommendations for cathartic use. They deferred hospital evaluation due to COVID despite continued symptoms. Upon presentation, he had mild tachycardia with an abdominal exam noting distention but no pain on palpation. Labs showed leukocytosis and multiple electrolyte abnormalities. CT abdomen with contrast showed marked diffuse large bowel dilation and sigmoid volvulus, but without any bowel wallpneumatosis(Figure 2). He underwent emergent colonoscopy showing torsion in the distal and proximal sigmoid, with a dilated area of dusky mucosa with mucopurulent discharge, concerning for ischemic bowel(Figure 3). After detorsion, he had an emergent exploratory laparotomy with resection of his left and sigmoid colon due to gangrenous bowel.Two hours later in the Intensive Care Unit, he passed away due to an asystole event. Discussion: Despite expeditious guideline-based treatments that were performed, the patient passed away within 12 hoursfrom presentation to the hospital. General mortality rates for sigmoid volvulus have decreased significantly recently from 50% to 10%. However, this patient already had gangrenous bowel on initial endoscopy due to the lengthy time of symptoms (13 days) prior to presentation. This highlights the potential dangers associated with delayed presentation related to changes in management via telemedicine as well as patient fears regarding COVID transmission. Further inquiry is indicated to examine the effect of the pandemic on other GI-related emergencies and their management.
Timeline of outpatient phone calls that were made by the patient's wife to his primary care physician (PCP) or to the Movement Disorder Clinic in the Neurology department.
Marked diffuse large bowel dilation measuring up to 7.2 cm in diameter. Swelling of the sigmoid mesentery with abrupt caliber change in the mid sigmoid colon, consistent with sigmoid volvulus. No bowel wall pneumatosis or abnormal enhancement.
Classic endoscopic findings of sigmoid volvulus were seen - including two points of torsion seen in the distal and proximal sigmoid colon. Once those points were passed, dusky mucosa with purulent discharge was seen in the descending colon, concerning for bowel ischemia.
Disclosures: Tenzin Choden indicated no relevant financial relationships. Ilan Vavilin indicated no relevant financial relationships. Thomas Loughney indicated no relevant financial relationships.