or renal insufficiency. A water deprivation test and desmopressin challenge confirmed central diabetes insipidus. Brain MRI of the pituitary revealed diffusely enlarged pituitary gland and stalk with homogenous enhancement. Her hypernatremia and polyuria corrected with 100mcg desmopressin. Pituitary hormone levels were only significant for low ACTH. Before further testing, she was readmitted two weeks later for persistent nausea and vomiting with coffee ground emesis. EGD revealed a large peri-pyloric mass, positive for signet ring cell adenocarcinoma. Before the colonoscopy could be performed, the patient developed cardiogenic shock, was resuscitated and ultimately passed away. Discussion: Pulmonary embolism can often be the first presentation of an occult or overt malignancy and studies have shown higher rates of VTE associated with stomach and pancreatic
cancers. One study reported a 9.4% incidence of being diagnosed with cancer within the first year of having a primary VTE event. Our case highlights the importance of having high-index clinical suspicion of occult, often metastatic malignancy in patients presenting with unprovoked PE. Most common malignancies associated with pituitary metastasis are lung and breast adenocarcinoma. Our patient did not get a pituitary biopsy due to high risk of bleeding in the setting of recent PE on therapeutic anticoagulation but was later noted to have adenocarcinoma of the stomach which carries the highest risk for bleeding. Additionally, her new onset CDI with pituitary stalk enhancement made it a particularly challenging case. A high index of suspicion in patients with unexplained pulmonary embolism and a quick follow-up for age-appropriate cancer screening and preventative measures can ensure timely diagnosis and treatment.
EMERGENT NON-OPERATIVE ENDOSCOPIC DECOMPRESSION THERAPY IN A CASE OF OGILVIE’S SYNDROME
Hirrah Sajjad, Saifullah M. Shahid, Pavana Sakhamuri, Parker L. Ellison, Stephen Landreneau, Nisha Loganantharaj; Department of Medicine, LSU Health Sciences Center, Lafayette, LA.
Introduction: Ogilvie’s syndrome, also known as acute colonic pseudo-obstruction (ACPO), is a rare cause of benign intestinal dilation in the absence of a mechanical obstruction. However, if left untreated, this can lead to detrimental outcomes such as bowel ischemia and spontaneous bowel perforation. The exact mechanism of colonic dilation is still unknown but recent surgical intervention, prolonged opioid course, and critical illnesses can be provoking factors. Case: A 40-year-old female presented with acute- onset, severe, painful abdominal distention secondary to obstipation. On presentation, the patient was tachycardic, tachypneic, and febrile with a leukocytosis. She had a past medical history of GSW status-post explorative laparotomy and small bowel obstruction status-post surgical intervention one month prior while on chronic opioid therapy. Initial imaging including CT abdomen and pelvis with contrast revealed a dilated transverse colon up to 13cm without evidence of mechanical
obstruction. General surgery and gastroenterology were consulted. After initial assessment, plan was to begin with a less invasive approach, so she underwent emergent flexible sigmoidoscopy with rectal tube placement for decompression therapy. Within 24 hours following the procedure, patient felt symptomatic relief as evidenced by the passing of flatus and, eventually, stool. Her etiology of pseudo-obstruction was thought to be likely secondary to stricture formation given recent surgery in the setting of chronic opioid use. Discussion: Although the exact etiology of Ogilvie’s syndrome is unknown, early identification and intervention with conservative endoscopic therapy can prevent the development of critical bowel ischemia and perforation caused by colonic dilation and stool impaction. This case highlights the effectiveness of non-operative management in cases of known obstruction without evidence of extrinsic compression or intrinsic mass effect.
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