Transcript Second Place - Steve Kriss, DO, FACOFP, FAWM

CDR Steven Kriss, MC, USN, Family Practice/Sports
Medicine, Naval Hospital Camp Pendleton, California
16 APRIL 2010
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Military Disclaimer
1. “The views expressed in this article are those of the
author and do not necessarily reflect the official policy
or position of the Department of the Navy, Department of
Defense or the United States Government.”
2. “I am a military service member. This work was
prepared as part of my official duties. Title 17 U.S.C. 105
provides that ‘Copyright protection under this title is not
available for any work of the United States Government.’
Title 17 U.S.C. 101 defines a United States Government work
as a work prepared by a military service member or
employee of the United States Government as part of that
person’s official duties.”
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Endurance events
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CC: Abd Pain, Diarrhea, Nausea, Weakness
• HPI: 42 yom presented to ED 2 hrs S/P 1st Marathon
• C/O severe, intermittent abd pain, nausea, putrid red•
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black loose stools and profound weakness
Brought to ED after multiple episodes of hematochezia ;
could not tol po
Voided after race; brownish-red
Race conditions: Sunny, 65F (20 degrees higher than
training conditions), “hilly”
Trained 3 mos, 3-4x/wk, longest run=23 miles
During race drank 32 oz Gatorade, several small cups H2O ;
ate 2 energy cubes
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Race Progress
 8:15-8:30/mile pace x 18 miles (run)
 Expd abd pain/cramping, light-headedness
 9:30-10:00/mile pace x last 8.2 miles (jog/walk)
 Completed race in 3:57:00
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ROS
 +Lightheadedness; no HA
 +Nausea and Diarrhea; no Vomiting
 No CP or SOB
 No Back Pain
 No Fever or Chills; No Night Sweats
 NL BM (1) before the race
 Bronchitis x 3 wks ended 2 days prior to Marathon
 Wife had VGE 2 wks before race, lasted 7 days
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History
 PMedHx: Occasional Migraine HAs, Allergic Rhinitis
 PSurgHx: L. MMT/Partial Meniscectomy (1988), R.
UCL tear/repair (1995)
 FamHx: Migraine HAs, Allergic Rhinitis, AFib, MVP,
HTN, Hernias, Psoriatic Arthritis
 Soc Hx: 1 Beer/day, No Tobacco, No Supplements
 Meds: Flonase, Occas Excedrin; took 1 before race
 NKDA
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Questions and Answers (Q&A)
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Physical Exam
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VS: T=98.9F, HR=90, BP=130/90, RR=20, O2Sats=99%
Gen: A/O x 3, pale, lying in fetal pos, occas writhing
HEENT: MM dry, otherwise NL
Lungs: CTAB
Cardiac: RRR
Abd: Mild-Mod TTP 4 Quads, BS hyperactive, no
rebound , no McBurney’s pt TTP, Murphy’s sign neg,
no bruits, no masses, no CVA TTP. Rectal: declined
 MS: NL
 Neuro: CN II-XII intact
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Differential Diagnosis (Q&A)
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Tests and Results
 ECG: NSR (rate=75), No ST-T changes
 Chem: (Abn) Glucose=120, CK=2672
 CBC: (Abn) WBC=13.2
 UA: (Abn) SG=1.031, bili=small, ketones=large,
blood=trace, protein=30, leukest=small,
bacteria=many
 Imaging: None
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Differential Diagnosis (DDx)
 Appendicitis
 Abdominal Aortic Aneurysm (AAA)
 Mesenteric Ischemia
 Abdominal Migraine (Migraine Variant)
 Viral Gastroenteritis (VGE)
 Diverticulitis
 Ischemic Colitis (Infectious/Inflammatory)
 Myocardial Infarction (MI)
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Working DDx
 Mesenteric Ischemia
 Diverticulitis
 VGE
 Abdominal Migraine
 Ischemic Colitis
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Treatment
 100 % Oxygen (NC)
 2L NS boluses (IV)
 Rest/Relative bowel rest
 Analgesics declined by pt
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Outcome
 4 hrs in ED pt was feeling somewhat better
 Produced light-colored urine and flatus
 Hematochezia resolved
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lightheadedness
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energy
 No dry mouth or thirst
 Intermittent abd pain (moderate); abd exam benign
 VS (before DC): T=98.1F, HR=60, BP=115/70, RR=12,
 O2Sats=100% (RA)
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Discharge Diagnoses
1. Heat Exhaustion
2. Dehydration
3. Exercise-induced Ischemic Colitis
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Literature Review
 Searches were conducted using:
1. Ovid
2. Pub Med
3. Up to Date/E-Medicine
* 4 good quality articles
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Articles
1. Lucas W, Schroy PC. Reversible ischemic colitis
in a high endurance athlete. Am J Gastroenterol.
1998; 93: 2231-2234.
2. Cohen DC, Skipworth JR. Marathon-induced ischemic
colitis: why running is not always good for you. Am J
Emerg Med. 2009; 27: 255.e5-255.e7.
3. Sanchez LD, Corwell B, Berkoff D, Pedrosa I. Ischemic
colitis in marathon runners: A case-based review.
J Emerg Med. 2006; 30: 321-326.
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Articles (cont)
4. Moses FM. Exercise-associated intestinal ischemia.
Curr Sports Med Rep. 2005; 4: 91-95.
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Article 1 - Case
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30 yof elite runner ran highly competitive marathon
Developed crampy abd pain during race; hematochezia
On OCP-s
Admitted to Hosp
Sigmoidoscopy demonstrated patchy erythema, friability,
exudate in rectum, severe hemorrhagic segmental colitis in
the sigmoid colon.
 Histology demonstrated hemorrhagic necrosis of the
mucosa with stromal hemorrhage, crypt effacement and
mucopurulent exudate
 Pt recd IV Fluids, bowel rest, Abx - DC and did well
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Sigmoidoscopy
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Histology
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Article 2 - Case
 31 yom amateur runner collapsed after completing London
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marathon. Shortly after, he presented to ED.
After 16 mi began having cramps and hematochezia
CT (contrast-enhanced) revealed thickened and enhancing
cecum and ascending colon, representing ischemic colitis
Admitted to Hosp, given O2, IV Fluids, analgesics
Peritoneal signs developed after 48 hrs
Pt underwent laparotomy, R. hemicolectomy/ileostomy
Operative and histologic findings confirmed ischemic
colitis of cecum and proximal colon
DC well after 10 d; ileostomy reversed later
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Computed Tomography (CT)
Figure 27. Diffuse ischemic colitis.
Horton K M et al. Radiographics 2000;20:399-418
©2000 by Radiological Society of North America
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Article 3 - Review
 In 2002 there were 200 marathons in the U.S.
 30,000 runners in some races ; 43 % over age 40
 More pts presenting to ED-s/clinics
 30-80% of long-distance runners report GI complaints
 16% have had bloody diarrhea after a race or run
 7 previous pts reported in literature with ischemic
colitis (2 men; 5 women; 2 gender not specified)
 OCP-s used in 2/5 women
 NSAIDS used in 3/7 cases
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Article 3 (cont)
Proposed mechanisms of ischemic colitis:
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Mesenteric blood flow (reduced 80% in exercise)
 Mechanical trauma from moving/vibration
 Dehydration ; hypovolemia
 Hyperthermia
 OCP-s
 NSAIDS
 Tegaserod (Zelnorm), a 5-HT4 receptor antagonist
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Article 3 (cont)
 CT useful to detect colon abnormalities that support
clinical diagnosis of ischemic colitis
 Used to R/O appendicitis, diverticulitis, mesenteric
thrombosis, AAA
 Findings in ischemic colitis: colon wall thickening,
enhancement of mucosa, edema, loss of haustra
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Article 4
 To R/O mesenteric infarction in pts with pain out of
proportion and peritoneal signs mesenteric angiography is
the procedure of choice
 Abdominal pain and diarrhea are the initial symptoms of
ischemia which usually limit further damage by inhibiting
activity. This threshold may be exceeded during extreme
athletic competition and endurance events
 Ischemic colitis is usually mild but may require volume and
transfusion support, rarely progressing to resection or
stricture
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Pt Follow Up
 Pt cont to have intermittent abd pains and
hematochezia x 12 hrs
 Diet: yogurt, banana and Gatorade
 Next day, felt NL except for occas abd pain
 VS NL
 Returned to work as an FP Sports Medicine Fellow
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Key Teaching Points
1. a. For Acute Abdominal Pain presenting to the ED or FP
Clinic, life-threatening diagnoses must be R/O.
1. b. Along with H & P, Abdominal CT is extremely helpful
in ruling out serious diagnoses in this setting.
2. a. Exercise (Marathon)-induced Ischemic Colitis is a
condition more likely to present to the ED or FP Clinic
during or after extreme endurance sporting events.
2. b. Treatment is IV Fluids, O2, analgesics, rest and F/U.
3. a. Most cases do well, however, serious cases of exerciseinduced ischemic colitis have been documented, requiring
rapid diagnosis, surgical intervention and even colectomy.
3. b. Educate athletes and coaches alike and be vigilant.
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Thank You
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