Case 16-2001

Abstract

A 17-year-old girl (gravida 1, para 1) was admitted to the hospital because of abdominal pain, fever, and diarrhea.The patient had been in good health before admission. Three weeks earlier, she had undergone a cesarean section because of multiple bouts of fetal bradycardia; the infant was delivered at 40 weeks of gestation. The pregnancy was otherwise uneventful. She received a single dose of gentamicin and two doses of clindamycin intravenously in the peripartum period. Her postpartum course was uneventful, and she was discharged on the third postoperative day.Three days before admission, the patient began to have pain in the right lower quadrant of her abdomen. The pain became more severe the next day and was accompanied by very frequent, watery stools that were brown and later black, nausea, and a temperature that peaked at 38.3°C. She passed no fresh blood. One day before admission, 2 liters of fluid with electrolytes was administered intravenously. On the day of admission, the pain became more severe and was unrelieved by acetaminophen-oxycodone, although the diarrhea had ceased.The patient did not have a history of previous abdominal pain or exposure to patients with gastroenteritis, and there was no family history of inflammatory bowel disease. She resided in eastern Massachusetts.The temperature was 38.7°C, the pulse was 104, and the respirations were 16. The blood pressure was 130/70 mm Hg.On examination, the patient was in considerable pain. Her abdomen was soft but exquisitely tender in the right lower quadrant, without rebound tenderness; bowel sounds were diminished. A stool specimen contained occult blood.The urine was normal; the sediment contained 0 to 2 red cells and 3 to 5 white cells per high-power field. The results of hematologic studies performed at various times during the hospital stay are shown in Table 1. Blood chemical values were normal. A computed tomographic (CT) scan of the abdomen and pelvis, obtained after the rectal administration of contrast material (Fig. 1), revealed concentric thickening of the wall of the cecum and proximal ascending colon, with fat stranding and prominent lymph nodes in the adjacent mesentery. A transabdominal and transvaginal ultrasonographic study of the pelvis showed no abnormalities.Morphine was given intravenously. A blood specimen and a rectal swab were obtained for culture. Ampicillin, gentamicin, and fluid and electrolytes were administered intravenously; heparin was injected subcutaneously, and metronidazole was given orally. Total parenteral nutrition was instituted. The temperature rose to 39.1°C on the first hospital day. The uterus was not tender; its size corresponded to a 12-week gestation; there was no discharge.On the second hospital day, the temperature rose to 38.8°C. Blood chemical tests were performed on this day and subsequently during the hospital course ( Table 2). An abdominal radiograph showed no abnormalities. The administration of analgesia, controlled by the patient, was begun. The pain improved briefly, but the patient refused...