GI Dysmotility: A Case Report

Abstract

A 75-year-old male, with a medical history of diabetes, hypertension, coronary artery disease, status post coronary artery bypass graft, and left-sided breast cancer, status post left breast mastectomy, was transferred from an outside hospital with complaints of a month of constipation, nausea and vomiting. The patient presented to an OSH a month prior with recent onset of constipation, with no bowel movements for 10 days, changed from his usual habit of daily bowel movements. He initially responded to lactulose with a bowel movement and was discharged on a regimen of stool softeners and laxatives; however, upon returning home, he was again unable to move his bowels despite his bowel regimen and developed diffuse abdominal pain, nausea and vomiting secondary to distension. An outpatient esophagogastroduodenoscopy (EGD) showed that the patient had a normal esophagus and a large amount of retained food in the stomach, concerning for gastroparesis. This finding was thought to be secondary to his diabetes, despite his well-controlled blood sugars and a hemoglobin A1c of 7.0 %. After two further weeks of constipation, the patient was readmitted to the OSH with abdominal pain, intractable nausea and vomiting, as well as a 20-25 lbs weight loss since his symptoms began. Imaging showed colonic gaseous distention, with the cecum dilated to 9.5 cm, and an un-prepped sigmoidoscopy was performed, showing no inflammation, polyps or masses; of note, a screening colonoscopy done 4 months prior identified and removed multiple benign polyps. A CT scan of his abdomen and pelvis also did not show any obstructing colonic masses. He was presumed to have colonic pseudo-obstruction, or Ogilvie Syndrome. Erythromycin was started without effect. He was subsequently given neostigmine, which was also unsuccessful in relieving his symptoms. The patient was then referred to another OSH for further workup. A 4-day gut motility study showed a pan-GI dysmotility disorder. Furthermore, a gastric emptying study revealed markedly delayed gastric emptying of both solid and liquid foods, but defecography was entirely normal. Non-contrast CTs of the chest, abdomen and pelvis again did not identify any masses or bowel obstruction, but did show enlarged precarinal lymph nodes and prostatomegaly, as well as small thyroid nodules bilaterally. As the patient continued to fail to have a bowel movement and could not tolerate a diet, he was started on total parenteral nutrition and was transferred to Thomas Jefferson University Hospital (TJUH) for further evaluation.On presentation to TJUH, the patient complained of occasional diffuse abdominal pain and distention, as well as nausea. He had not had any vomiting since he stopped eating when he was started on TPN. He denied any swallowing difficulty but did complain of constantly spitting up clear sputum. He had not had a bowel movement in more than 4 weeks since his initial response to lactulose at the first OSH. He had lost 30 lbs in the 4 weeks since his symptoms began. His review of systems was other wise...