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This week's case is
A 25-Year-Old Man With
Crohn's Disease, Diarrhea and Confusion
A 25-year-old white man with a medical history of Crohn's disease came
to the emergency room with a 3-week history of daily diarrhea. He states
that his Crohn's disease has been symptomatic for 3 years. The night prior
to presentation he awoke with mild abdominal pain. Since that time, the
waves of abdominal pain have increased in frequency and intensity. The
patient now complains of continuous nausea and 3 episodes of emesis. Past
medical history is remarkable only for Crohn's disease, which was diagnosed
5 years ago. No surgical therapy has been required; however, the patient
has been hospitalized twice in the past for exacerbations. Currently, he
takes no medications.
Physical examination shows mild orthostatic hypotension, hyperactive
bowel sounds, and mild diffuse abdominal tenderness. There is no rebound
tenderness. The patient is alert, oriented, and able to follow 3-step commands.
Plain abdominal x-rays show dilated loops of small bowel. Blood drawn for
electrolyte analysis revealed slight hypokalemia. The patient was admitted
to the hospital and administered hydrocortisone 100 mg IV every 6 hours
and Azulfidine suppositories. Five percent dextrose solution in 0.45 normal
saline with supplementary potassium chloride was given intravenously to
maintain hydration. Tigan suppositories were used to control nausea, and
meperidine was ordered for pain. No oral feedings were given.
Over the next 24 hours the patient improved. There was less abdominal
pain and diarrhea; however, nausea persisted. There was one episode of
emesis. The next day the patient was found to be unsteady while walking
in the hall. His blood pressure was normal, and he was placed on bed rest.
Later that evening the patient repeatedly attempted to leave his bed despite
instructions from his nurse. He stated that he needed to clean the garage.
He was not oriented to time or place. The nurse described him as globally
confused. The physician on call was asked to evaluate the patient.
Question 1
Discuss the differential diagnosis of confusion in this patient.
What additional information would be helpful in determining the etiology
of his symptoms?
Question 1 - Crohn's Disease And Other Causes of Altered Mental Status
Discuss the differential diagnosis of confusion in this patient.
What additional information would be helpful in determining the etiology
of his symptoms?
Answer :Causes of mental confusion in this
patient can be divided into the following categories: drug effect/withdrawal,
metabolic, infectious, neurologic, and psychiatric.
Effects of medications may be due to an adverse reaction or withdrawal
(e.g., secondary to dependence). Narcotics (meperidine), steroids (hydrocortisone),
and antihistamines (Tigan) may be associated with altered mental status.
This is especially true in the elderly where marked mental status changes
may occur with even small doses of these medications. Furthermore, given
the present epidemic of drug abuse among young adults, one should consider
illicit drug use or alcohol withdrawal. In the latter condition, symptoms
of agitation, confusion, and tremor will begin 24 to 48 hours after abstinence.
When alcohol withdrawal occurs, delirium tremens may occur. Autonomic hyperactivity
(tremulousness, sweating, tachycardia, elevated blood pressure) and acute
confusion are the hallmarks of this syndrome. Benzodiazepine withdrawal
is a commonly encountered drug withdrawal syndrome. Blood and urine toxicology
screens help to establish the diagnosis of drug withdrawal.
Electrolyte abnormalities may be associated with confusion. Hyponatremia
is of particular concern in this patient given the history of diarrhea.
Patients with inflammatory bowel disease may be treated with long courses
of corticosteroids on a long-term basis. Abrupt withdrawal of corticosteroids
can lead to Addisonian crisis. Hyperglycemia should also be considered
given the use of intravenous dextrose and steroid treatment. Abnormalities
in calcium homeostasis can also cause altered mental status as may uremia,
hepatic encephalopathy, folate deficiency, and B12 deficiency.
In a patient with fever and altered mental status, meningitis must be
considered. Physical findings that may support this diagnosis are fever,
nuchal rigidity, leukocytosis, and Kernig's or Brudzinski's sign. Systemic
infections may also be associated with altered mental status, especially
in the elderly.
Hospitalization may be an important stressor. For example, patients
with histories of psychiatric disease may decompensate during hospitalization.
Bipolar disorder, agitated or psychotic depression, and schizophrenia should
all be considered. Patients without past psychiatric disease may develop
anxiety, agitation, or depression.
Possible neurologic causes of altered mental status in this patient
include cerebral mass lesion, cerebellar infarction, or nutritional deficiencies
associated with chronic diarrhea or gastrointestinal disturbance.
When considering the differential diagnosis, don't overlook the patient's
most pertinent medical diagnosis: Crohn's Disease. Read more about this
malady and the associated nausea, vomiting and diarrhea that this patient
is experiencing.
Question 2
The house officer evaluating the patient noted the following information:
blood pressure was 130/80 mm Hg, pulse rate 90 bpm, breathing rate 16/minute,
and temperature 99.2°F. A chemistry profile drawn 2 hours earlier showed
no significant abnormalities. CBC was unremarkable. No Tigan or meperidine
had been administered for 6 hours. The last steroid dose was administered
5 hours earlier. Blood and urine toxicology screens were negative. The
patient's wife confirmed the unusual nature of the patient's current behavior
and the lack of a psychiatric history.
How does this information help one focus on the differential diagnosis
of confusion in this patient and what aspects of the physical examination
should be emphasized?
Question 2 - Evaluation of the Patient With Altered Mental Status
How does this information help one focus on the differential diagnosis
of confusion in this patient and what aspects of the physical examination
should be emphasized?
Answer:The absence of metabolic abnormalities
or drug toxicity on screening blood chemistry, urine, and other studies
makes the diagnosis of toxic-metabolic disorder unlikely. Furthermore,
no therapeutic drugs have been given in the last 6 hours. Despite the lack
of fever or change in the WBC, an infectious process such as peritonitis
could be present. A detailed abdominal examination should be performed.
Psychiatric disease is unlikely given the nature of the symptoms and the
lack of a past history of psychiatric disease. A detailed neurologic examination
should be performed at this juncture.
Question 3
History and physical examination showed that the patient denied abdominal
pain or headache. He did complain of intermittent blurred vision. Abdominal
examination was unremarkable. He was oriented to person only and was able
to follow one-step commands. There was global confusion and slight agitation.
Recent memory was impaired, but long-term memory was intact. The patient
complained of double vision on lateral gaze, and there was limitation of
lateral eye movements bilaterally. Motor power was normal, and deep tendon
reflexes were diminished in the legs. There was mild dysmetria on finger-to-nose
testing and marked heel-to-shin ataxia. Gait was wide-based.
What is the proper diagnosis and treatment?
Question 3 - Wenicke's Encephalopathy
What is the proper diagnosis and treatment?
Answer:Ataxia, global confusion, and ophthalmoplegia
are hallmarks of Wernicke's encephalopathy, a condition associated with
a deficiency of thiamine. In this case, thiamine deficiency was likely
linked to chronic diarrhea and Crohn's disease. Thiamine is necessary for
glucose metabolism. The condition was precipitated in this patient after
intravenous dextrose infusion in the absence of adequate thiamine supplementation.
Acute treatment of Wernicke's encephalopathy includes intravenous thiamine
followed by oral thiamine. If the diagnosis is correct, ophthalmoplegia
may resolve quickly, often within 30 minutes. Ataxia and confusion may
resolve promptly with intravenous thiamine therapy but often persist for
a longer period of time.
Wernicke's encephalopathy is traditionally a disease of alcoholics with
poor nutritional intake. Wernicke's encephalopathy should be considered
whenever confusion develops in a poorly nourished patient. This is an example
of how even the most benign-appearing interventions may become problematic.
As this case illustrates, frequent emesis or chronic diarrhea can also
be associated with thiamine deficiency. This disorder has also been described
in morbidly obese patients who have had gastroplasty.
In Wernicke's encephalopathy there is ataxia. Many types of ocular abnormalities
can be present. The most common is bilateral horizontal nystagmus (85%).
Bilateral sixth cranial nerve palsy is found in 54% of patients and conjugate
gaze palsy in 45%. Less common findings include ptosis, anisocoria, and
retinal hemorrhage. The mental confusion of Wernicke's encephalopathy is
often characterized by apathy, spacial disorientation, and diminished short-term
memory. Over 80% of these patients progress to exhibit Korsakoff's psychosis,
which is characterized by retrograde and anterograde amnesia with confabulation.
Approximately 25% of these patients will fail to recover.
At autopsy in patients with Wernicke's encephalopathy, lesions are often
found in the mammillary bodies, cerebellum, hypothalamic nuclei, and in
periaquaductal regions of the brainstem. Transketolase activity which is
low in thiamine deficient states is a laboratory assay that may be useful
in the diagnosis of Wernicke's encephalopathy.
