Abstract Introduction Patients often seek emergency healthcare with extensive comorbidities which can lead to extended hospital stays, delays in treatment, and fragmentation of care between practitioners. This case highlights challenges in clinical decision making, unique presentations, and multi-system management. Description A 76-year-old male presented for evaluation of shortness of breath and dizziness following weeks of dark stools. His past medical history was most notable for valvular atrial fibrillation s/p aortic and mitral valve replacement on warfarin, biventricular pacing implanted cardioverter defibrillator (ICD), hypertension, hyperlipidemia, heart failure with preserved ejection fraction, and remote history of pulmonary embolism. He was admitted for evaluation of gastrointestinal bleeding with initial hemoglobin of 8.9g/dL. Workup included having a normal esophagogastroduodenoscopy, colonoscopy with polyps and diverticulosis, and video capsule endoscopy with a possible small bowel angioectasia. Hemoglobin stabilized and discussion regarding transfer for push enteroscopy commenced. On hospital day 16, patient was transferred to the Intensive Care Unit (ICU) after worsening dyspnea following an episode of emesis and ongoing reflux symptoms. Workup on transfer revealed elevated troponin of 730ng/L and a lactate of 5.4 mmol/L. Computed Tomography (CT) Angiography revealed possible distal superior mesenteric artery (SMA) occlusion with ileal wall thickening. Discussions were had with radiology, interventional radiology, general and vascular surgery with no plan for acute procedural intervention. He was continued on a heparin drip for atrial fibrillation, possible Acute Coronary Syndrome (ACS), and possible SMA thrombosis.Patient had persistent reflux symptoms and uptrending troponins. Repeat electrocardiogram showed ventricular-paced rhythm which was concerning for ACS. Cardiology recommended transfer to quarternary center for push enteroscopy prior to coronary angiography. While awaiting transfer, he continued to have reflux, up-trending troponin with normal creatine kinase-MB and unchanged echocardiogram. Subsequently, patient began to spike fevers on antibiotics and CT Chest/Abdomen/Pelvis revealed extensive bowel necrosis (90cm). General surgery performed emergent bowel resection. Post-operatively, lactate and troponin downtrended, and reflux resolved. Following the bowel resection, the patient’s hospital course was complicated by staged-abdominal closure, short duration of ventilatory and vasopressor support, renal replacement therapy, total parenteral nutrition, gastrointestinal bleeding from nasogastric-tube, and transient ischemic attack. Ultimately, the patient had renal recovery, underwent inpatient rehab, and was discharged home on hospital day 60. Discussion This case exemplifies the challenges in coordinating care for complex patients with overlapping pathologies, interrelated comorbidities, and multisystem involvement. Elderly patients with multiple comorbidities require physicians to maintain a broad differential, recurrent thorough examination, meticulous coordination, and timely multidisciplinary interventions. This abstract is funded by: None
Jones et al. (Fri,) studied this question.