P043: ELUSIVE EPISODIC HEMORRHAGIC SHOCK IN CROHN'S DISEASE WITH AMPLIFIED MUSCULOSKELETAL PAIN SYNDROME: A CASE REPORT
Edward K Maybury, DO1; Derek Marske, DO1; Zachary Affrin, MD2; Kumaran Senthil, MD2
1Naval Aerospace Medical Institute, Naval Aviation Schools Command, Pensacola, FL; 2Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, PA
Background: A 21-year-old female with Crohn's disease and amplified musculoskeletal pain syndrome (AMPS) presented to the emergency room with syncope, tachycardia, and hypotension in the setting of episodic large volume bloody stools. After initial stabilization, she was transferred to the pediatric intensive care unit (PICU), where she continued to have bleeding episodes and required multiple transfusions. The source of the bleeding proved elusive, but was eventually found. Ultimate resolution was achieved with an exploratory laparotomy (ex-lap) with diverting loop ileostomy after multiple failed interventional radiology (IR) embolization attempts.
Irritable bowel disease (IBD), which includes Crohn’s and Ulcerative Colitis, impacts approximately 24 million Americans. It is more common in white females and often diagnosed within the late teens to early twenties. Crohn’s disease can progress to profuse intestinal bleeding if inflammatory damage erodes into a vascular structure. It is critical to recognize the signs and symptoms of hemorrhagic shock and the aggressive treatment requirements for severe classes. Chronic pain syndromes represent a 60% comorbidity in patients with IBD, which can increase the difficulty in detecting early stages of hemorrhagic shock.
Case Description: A 21-year-old female with a history of AMPS and Crohn’s disease was admitted to the PICU in the setting of episodic large volume bloody stools, resulting in syncope, tachycardia and hypotension. During her first bleeding episode in the PICU, the patient rapidly decompensated to class IV hemorrhagic shock, but recovered quickly with rapid infusion of six units of packed red blood cells (pRBCs) and six units of fresh frozen plasma (FFP).
Prior to each of the patient’s three episodes of massive bloody bowel movements, her baseline abdominal pain worsened. This clinical presentation was utilized as a warning to prepare for massive transfusion.
Multiple abdominal computed tomography (CT) scans with contrast, IR angiographies, an esophagogastroduodenoscopy (EGD), a colonoscopy, and a diagnostic ex-lap were unable to elucidate the location of bleeding. It was ultimately found by conducting a CT scan immediately following an episode of abdominal pain similar to those which precipitated prior bleeding incidents.
Further IR angiography determined that the bleeding derived from a branch of the superior mesenteric artery in the distal ileum, however, three subsequent embolization attempts failed to halt the bleeding. Bleeding was ultimately stopped by a second ex-lap, which led to a distal ileal resection with a diverting loop ileostomy.
Discussion: In patients presenting to the PICU with a history of profuse gastrointestinal (GI) bleeding, access with two large-bore intravenous (IV) lines should be obtained for rapid transfusion purposes. Rapid infusers will fail to achieve maximum flow if catheters are too small or long, according to Poiseuille's law. Ultimately, this patient obtained a 14-gauge peripheral IV in addition to pre-existing18-gauge access. Identifying the location of bleeding in the small intestine, particularly in the ileum, can be elusive. Weighing the risks and benefits of obtaining imaging during symptomatic episodes requires careful coordination. Patients with AMPS may have distinct changes in pain sensorium during episodic bleeding, which should be heeded as a preamble to a hemorrhagic episode.
