Abstract

This case presents a 65-year-old female with a past medical history of HTN, osteoarthritis, GERD, and umbilical hernia was brought in by EMS for evaluation of abdominal pain and syncope. She was hypotensive and admitted to the ICU for septic shock. She reported a bowel movement when she experienced abdominal pain and LOC. The patient had prior wounds from a hernia repair with mesh placement done 13 years ago with draining fistulas in the LLQ for which she had replaced the bandages over them for years. CT scan showed pockets of fluid collection and an abscess in the left lower abdomen subcutaneous tissue. Bacterial cultures were positive for bacteroides fragilis. In the ICU, the patient had increasing tachypnea with a V/Q scan and CT angiography showing significant pulmonary embolism. The next day, the patient reports multiple bright red stools with hemoglobin dropped from 12.9 to 8.3. Colonoscopy during a heparin window revealed severe colitis above the rectum, deep confluent ulceration, violaceous discoloration suggestive of ischemia and a likely source of bacteroides fragilis bacteremia. Patient was started on metronidazole, cefepime and ceftazidime, fidaxomicin. For the next 7 days, H&H and CBC stabilized, and continued on low-intensity IV heparin until the rectal bleed improved. At the time of discharge, the patient had no frank blood in her bowel movements for the past 3 days, denied abdominal pain, and tolerated PO diet with continued outpatient follow-up.