Chronic Constipation Presenting with Severe Abdominal Pain

Abstract

An 80-year-old black male presents with severe abdominal distention and no bowel movement or gas per rectum for 3 days, as well as recent onset of vomiting. He has Parkinson’s disease and chronic constipation and lives in a nursing home. His medications include levodopa and benztropine, which he has been taking for several years. His temperature is 37 °C, heart rate 90/min, blood pressure 116/70 mmHg, and respiratory rate 22/min. He appears to be tachypneic but otherwise nontoxic, with mental status unaltered from his baseline. Lungs are clear to auscultation bilaterally. His abdomen is severely distended. He does not have any abdominal surgical scars. He is tympanitic but has no significant tenderness to palpation. There are no palpable hernias, and rectal exam demonstrates an absence of stool and no palpable masses or strictures. Laboratory tests include metabolic panel with BUN 26 mg/dL (normal 7–21 mg/dL), creatinine 1.4 mg/dL (0.5–1.4 mg/dL) and electrolytes within normal limits, white blood cell (WBC) 6.8 × 10³/μL (4.1–10.9 × 10³/μL), lactate 0.9 mmol/L (0.5–2.2 mmol/L), and arterial blood gas (ABG): pH 7.48//PaCO2 30//PaO2 80//HCO3 24//SpO2 99%. A plain upright abdominal radiograph shows a massively dilated loop of sigmoid colon with the apex pointing toward the right upper quadrant, consistent with the “coffee bean” or “bent inner tube” sign; upright chest radiograph shows no free air under the diaphragm.