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CDR Steven Kriss, MC, USN, Family Practice/Sports Medicine, Naval Hospital Camp Pendleton, California 16 APRIL 2010 1.

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Presentation on theme: "CDR Steven Kriss, MC, USN, Family Practice/Sports Medicine, Naval Hospital Camp Pendleton, California 16 APRIL 2010 1."— Presentation transcript:

1 CDR Steven Kriss, MC, USN, Family Practice/Sports Medicine, Naval Hospital Camp Pendleton, California 16 APRIL 2010 1

2 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.” 2

3 Endurance events 3

4 CC: Abd Pain, Diarrhea, Nausea, Weakness HPI: 42 yom presented to ED 2 hrs S/P 1 st Marathon C/O severe, intermittent abd pain, nausea, putrid red- 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 4

5 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 5

6 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 6

7 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 7

8 Questions and Answers (Q&A) 8

9 Physical Exam 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 9

10 Differential Diagnosis (Q&A) 10

11 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 11

12 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) 12

13 Working DDx Mesenteric Ischemia Diverticulitis VGE Abdominal Migraine Ischemic Colitis 13

14 Treatment 100 % Oxygen (NC) 2L NS boluses (IV) Rest/Relative bowel rest Analgesics declined by pt 14

15 Outcome 4 hrs in ED pt was feeling somewhat better Produced light-colored urine and flatus Hematochezia resolved lightheadedness 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) 15

16 Discharge Diagnoses 1. Heat Exhaustion 2. Dehydration 3. Exercise-induced Ischemic Colitis 16

17 Literature Review Searches were conducted using: 1. Ovid 2. Pub Med 3. Up to Date/E-Medicine * 4 good quality articles 17

18 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. 18

19 Articles (cont) 4. Moses FM. Exercise-associated intestinal ischemia. Curr Sports Med Rep. 2005; 4: 91-95. 19

20 Article 1 - Case 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 20

21 Sigmoidoscopy 21

22 Histology 22

23 Article 2 - Case 31 yom amateur runner collapsed after completing London 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 23

24 Computed Tomography (CT) 24

25 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 25

26 Article 3 (cont) Proposed mechanisms of ischemic colitis: 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 26

27 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 27

28 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 28

29 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 29

30 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 exercise- induced ischemic colitis have been documented, requiring rapid diagnosis, surgical intervention and even colectomy. 3. b. Educate athletes and coaches alike and be vigilant. 30

31 Thank You 31

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