Eat your heart out: Right heart collapse from bowel obstruction.
Assar S, Nakhle A, and Lazar M. Eat your heart out: Right heart collapse from bowel obstruction. Am J Respir Crit Care Med 2017; 195.
Am J Respir Crit Care Med
Shock is a life-threatening failure of the circulatory system leading to multi-organ failure and death. The timely and effective management of shock is based on diagnosing and treating the underlying condition. While a patient may present in shock secondary to presumed sepsis, it is important to consider the combination of more than one type of shock. We present a case of an elderly gentleman with refractory shock due to an unusual cause. Case: 72 year old gentleman with past medical history of childhood poliomyelitis causing functional quadriplegia, hypertension and recurrent clostridium difficile infection requiring fecal transplantation who presented with diarrhea, worsening dyspnea and leukocytosis. A CT scan of the chest and abdomen showed a significantly elevated right hemi-diaphragm and a dilated transverse colon which was displaced into the right chest. He was empirically started on treatment for C diff with oral vancomycin and intravenous metronidazole but he remained hypotensive requiring transfer to the intensive care unit where he was started on intravenous vasopressors. Subsequently, the patient developed multi-organ failure raising the concern for other etiologies of hypotension including obstructive shock. A bedside echocardiogram showed collapse of the right atrium which was thought to be secondary to mechanical obstruction from colonic intrathoracic displacement. The patient was taken to the operating room for decompressing colectomy with end ileostomy and he had rapid improvement in his clinical status and decrease in vasopressors need. The patient was continued on antibiotics for a total of ten days and was eventually discharged to subacute rehabilitation. Discussion: This is an unusual presentation of obstructive shock as most cases are secondary to tension pneumothorax, pulmonary embolism or cardiac tamponade. It is important to consider all types of shock when caring for a patient with refractory hypotension as there may be more than one process involved. In the case of this patient, bedside ultrasound was an invaluable tool in making the diagnosis of obstructive shock and led to the timely and appropriate treatment of the patient. Pathologically, paralysis of the right hemi-diaphragm from childhood poliomyelitis left him vulnerable to migration of bowel content into the chest causing increase intra-thoracic pressure and subsequent obstruction of the right heart outflow. While the initial perception was that his refractory shock was secondary to sepsis, obstruction of the right heart was a significant contributor. Decompression of his obstruction significantly reduced intraabdominal and intrathoracic pressure and quickly resolved his shock state. (Figure Presnted).