Diagnosis: Ischemic Colitis

History: 55 y/o male with h/o metastatic esophageal cancer (IIb). Pt is s/p transhiatal esophagectomy three years ago. He recently finished a round of chemotherapy. A PET 3 months ago demonstrated increase uptake in liver, L hip, and vague uptake in descending colon. The patient presents to ED w/ 1 day h/o “crampy” LLQ abd pain w/ nausea but no emesis. Complaints of constipation and not passing flatus. He also notes multiple episodes of “dry heaves”. He describes pain as coming in waves and acknowledges a decreased appetite. Denies melena, hematochezia, fever

Findings: AAS-1. Only noted for "single dilated loop of colon under an elevated left hemi-diaphragm." Patient sent home from the ER. CT-1. Patient received CT the next day. Similar findings noted (no acute pathology). Patient sent home again AAS-2A. Caliber change is noted in gas just distal to the splenic flexure concerning for obstruction. Patient admitted. AAS-2B (w/ Barium): Taken on day of admit (3rd day). A tortuous narrowing was observed w/ intermittent passage of contrast past splenic flexure. Also concerning for obstruction (partial) EGD-1 & EGD-2: show extrinsic compression, likely from the diaphragm. EGD-3: Dusky, friable mucosa seen c/w ischemic colitis

Ddx: Ischemic colitis Crohns Ulcerative Colitis Mesenteric Vascular Disease Infectious Colitis Psuedomembranous Colitis Colon Cancer Radiation Colitis NSAID lesions Pancreatitis

Dxhow: 1st: Upper endoscopy. 2nd: Open surgery after bowel perforation.

Exam: Vitals are within normal limits (afebrile) Abdomen was mildly distended. Moderate discomfort noted in LLQ upon palpation. No peritoneal signs. Rest of exam is benign