Urgent message: Prescribing Miralax and an enema would likely have killed this patient. He nearly died in the hospital. Can you figure out why?

WILLIAM A. GLUCKMAN, DO, MBA, FACEP, CPE, CPC
Constipation, a common urgent care complaint, can be a symptom of many things, not all of them obvious, and some life-threatening. In this tricky case, the underlying problem is one that many urgent care physicians would not consider in a differential diagnosis, yet a clue that the condition is a distinct—if uncommon—possibility is hidden in plain sight.

Case Presentation
JW is a 72-year-old male who presented to urgent care with four days of constipation. He had a history of hypertension. He had also had a partial colectomy for colon cancer 15 years earlier. He had not seen a physician in over 10 years, with one exception: a colonoscopy had been per- formed 1.5 years earlier and was reportedly normal.

JW stated that he normally had a soft BM every day and had never had constipation before. He was not on any medications. He denied any changes in his diet. He reported taking magnesium citrate at home earlier in the day. He had no BM but had experienced increasingly diffuse abdominal discomfort that was vague, with periods of cramping, but it was not “really” painful, he said. He was passing some flatus. His ROS was positive for a little nausea but no vomiting. On the day of presentation, he had eaten normally. He reported no recent black or bloody stools, no urinary problems, no fever, and no back pain. His social history was positive for smoking (>50 packs per year).

Observations/Findings
Evaluation of the patient revealed the following vital signs:
n T: 98.9° F
n R: 18
n  O2 Sat: 96% RA
n Pulse: 100
n BP: 210/110
The physical exam revealed JW to be a cachectic male who appeared to be his stated age and in NAD. His sclera were not icteric. His conjunctiva were not pale. His lung were CTA B/L. His heart was nml S1/S2, with no murmurs. His abdomen was flat, with slightly decreased bowel sounds.  No palpable  masses  were  detected, although there was some mild, diffuse tenderness without guarding or rebound. His femoral and DP pulses were strong and symmetric. There was no CVAT and his back had good ROM, without  pain.  His rectal  exam  showed  minute amount of stool in the vault that was trace gua- iac positive. His bladder was not distended.

Labs/Imaging
A KUB and CXR were obtained. They revealed a possible fecal impaction with ileus. The CXR showed a hilar mass. JW was sent to the local tertiary care ED for a CT scan of the C/A/P. The ED only did the A/P and admitted him to the floor of the medicine service with a vascular consult.

Diagnosis
5-cm abdominal aortic aneurysm (AAA).
Course and Treatment
Within 12 hours of admission, JW had a sudden onset of severe back pain and ruptured his AAA in front of his medical attending, sustaining a PEA cardiac arrest. He was resuscitated and transferred to the CCU, then taken promptly to the OR, where his AAA was repaired. JW survived to discharge and returned home after rehab to his wife.

Discussion
AAA may seem like a surprising diagnosis, but it should not be. The clue is JW’s risk factors. He is a pack-a-day smoker and has uncontrolled hypertension (he has a history of the condition and has not seen a doctor for it in over a decade). Tobacco use and uncontrolled hyper- tension are major risk factors for AAA.
While tobacco use and hypertension alone are not con- firmatory of the diagnosis, given the presentation and the patient’s age, AAA should be considered as one possibil- ity. Ischemic colitis, another life-threatening condition, should also be on the list.

The urgent care practitioner must remain vigilant and maintain a high index of suspicion for life-threatening intra-abdominal issues with all complaints of abdominal pain, no matter how seemingly minor. Constipation is not commonly the presenting symptom of AAA. A clinician could easily have been tempted to tell this gentleman to go home and take Miralax and an enema or another “constipation cocktail,” which would have resulted in dis- aster in this case.

A Surprising Cause for Constipation?

William Gluckman, DO, MBA, FACEP, CPE

Chief Executive Officer of FastER Urgent Care, Editorial Board Member for The Journal of Urgent Care Medicine
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