University of Cincinnati College of Medicine Cincinnati, OH, United States
Abigail Samuels, DO, MS, Brendan Collins, DO, Kris Ramprasad, MD University of Cincinnati College of Medicine, Cincinnati, OH
Introduction: Scleroderma (systemic sclerosis) is an autoimmune disease that can affect multiple organ systems and commonly involves the gastrointestinal tract. Small bowel pseudo-obstruction can occur when sclerosis of the bowel leads to reduced motility. Diagnosis can be challenging when presentation is virtually indistinguishable from mechanical obstruction.
Case Description/Methods: A 50-year-old female with past medical history significant for scleroderma/systemic lupus erythematous overlap syndrome, diffuse large B cell lymphoma and pulmonary arterial hypertension presented to the emergency department with complaints of acute onset severe abdominal pain, nausea and vomiting. The patient additionally described chronic diarrhea and recent fifty-pound weight loss; recent outpatient EGD and colonoscopy was noncontributory. Exam was concerning for acute abdomen. CT showed small-bowel obstruction with apparent transition point in the jejunal loops. On hospital day two exploratory laparotomy revealed dilated proximal small bowel with gradual progression to decompressed distal small bowel with no identifiable transition point. On postoperative day four patient clinically decompensated; repeat CT showed closed loop small bowel obstruction with two transition points in the central mid abdomen. The patient was taken to the OR for repeat exploratory laparotomy which was again negative for mechanical obstruction. Gastroenterology and rheumatology were consulted; she was diagnosed with scleroderma-related pseudo-obstruction complicated by small intestinal bacterial overgrowth. Total parenteral nutrition was utilized until return of bowel function. She experienced near resolution of her symptoms after a two-week course of antibiotics.
Discussion: Clinical signs and symptoms of small bowel obstruction are a medical emergency and should not be taken lightly. However, it is important to consider non-mechanical causes of obstruction in patients with rheumatologic conditions such as scleroderma to prevent unnecessary procedures when conservative management is warranted. This case is unique in that two CT scans performed during admission exhibited transition points, highly concerning for mechanical obstruction, prompting repetitive surgical intervention. This case illustrates that a multidisciplinary approach is essential to avoid misdiagnosis and unnecessary invasive procedures in this high-risk patient population.
Disclosures: Abigail Samuels indicated no relevant financial relationships. Brendan Collins indicated no relevant financial relationships. Kris Ramprasad indicated no relevant financial relationships.
Abigail Samuels, DO, MS, Brendan Collins, DO, Kris Ramprasad, MD. P2017 - A Difficult Diagnosis of Scleroderma-Related Small Bowel Pseudo-Obstruction With Radiographic Transition Point, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.