MCQ-discussion

[Hero]

A 67 yr old man presented to ER with palpitations and vomiting -- for two days. On examination-- irregularly irregular pulse of 136 bpm, central abdominal distention, and absent bowel sounds.Two weeks earlier-- sign of ventricular failure and EKG done at that time showed MI, pulse was regular rate 95 bpm. At that time he was given digoxin 0.125 mg tid and hydrochlorothiazide.The most likely cause of his abdominal distension is:
a-Ascities
b-Hypokalemia
c-Digoxin toxicity
d-Hepatic congestion
e-Mesenteric embolism

This is a very important, interesting as well as a tough question I think. Answer is very confusing as 2 options are very likely to be the cause for his abdominal distension in this case. Please discuss.

[bharat]

Originally Posted by Hero

A 67 yr old man presented to ER with palpitations and vomiting -- for two days. On examination-- irregularly irregular pulse of 136 bpm, central abdominal distention, and absent bowel sounds.Two weeks earlier-- sign of ventricular failure and EKG done at that time showed MI, pulse was regular rate 95 bpm. At that time he was given digoxin 0.125 mg tid and hydrochlorothiazide.The most likely cause of his abdominal distension is:
a-Ascities
b-Hypokalemia
c-Digoxin toxicity
d-Hepatic congestion
e-Mesenteric embolism

This is a very important, interesting as well as a tough question I think. Answer is very confusing as 2 options are very likely to be the cause for his abdominal distension in this case. Please discuss.

well hero let me try hai
well here patient seems to have digoxin toxicity because some feature like :-
1. Increased age of patients
2. symptoms of vomiting
3. treatment with hydrochlorothiazide(well it belongs to the main fator for causing hypokalemia and it is the main factor for for causing digoxin toxicity like you said two option are very likely to casue disease yes it's hard for me to choose between option B and C but B is the cause of C.
i will go for option c
please suggest me the cause ok

[Hero]

Good thinking Bharat. This patient seems to have digoxin toxicity coz after taking digoxin he developed palpitation, vomiting, atrial fibrillation, and the most important is-he is taking hydrochlorothiazide which might have caused hypokalemia, and hypokalemia is responsible for digoxin toxicity. Really nice thinking. But the question is what is the most likely cause for his abdominal distension? Since digoxin toxicity doesn't cause abdominal distension, so we need to think again. This patient has atrial fibrillation. Could it be possible that atrial fibrillation--->embolism-->superior mesenteric artery-->mesenteric embolism? Is it possible? I am not sure, but not a bad guess anyway. Another possible cause is hypokalemia causing paralytic ileus. Use ur brain.

[JNUS]

Most probably, its, e-Mesenteric embolism as described by Hero in his recent post.

[Hero]

JNUS, my first choice was the same--mesenteric embolism due to atrial fibrillation. But,if it is mesenteric embolism symptoms would include sudden onset of severe epigastric and periumbilical abdominal pain with minimal appreciable findings on abdominal examination ("pain out of proportion to physical findings"). Besides then abdominal distention would indicate bowel infarction and the patient will have more acute presentaion which is not the case here. Also abdominal pain would be a presenting complaint and in this case there is no abdominal pain mentioned. The most important thing we should know that in atrial fibrillation a clot usually doesn't develop in the first 48 hours. Of course we do not know wether the AF was there for a longer time but the rhythm was normal 2 days ago. That's why I dont think his abdominal distension is due to mesenteric embolism.
What do you say?

[Hero]

His presentation fits more into hypokalemia causing 1) dig toxicity --vomiting and atrial fibrillation and 2) paralytic ileus which presents with mild diffuse, continuous abdominal discomfort, nausea and vomiting, sometimes generalized abdominal distention and decreased or absent bowel sounds. And this patient has all these S&S, so I go with hypokalemia.

[Hero]

Answer was not given. S&S of this patient are suggesting hypokalemia or mesenteric embolism. Tough question but the most likely cause for his abdominal distension is hypokalemia.

[Hero]

Your opinion and suggestions are welcomed. And this is my 100th post, now I become a senior member...thanks to all

[JNUS]

Going into paralytic ileus and then develop abd. distension may not be so quick i mean within 2 days after hypokalemia ... actually i had not encountered so and had not read 'bout how quick it develops after hydrochlorthiazide..

May be clinical evidence are not much given to make it confusing , still i go for mesentric embolism..

i will discuss it with consultant tomorrow and will post after that...

[bharat]

Originally Posted by Hero

Good thinking Bharat. This patient seems to have digoxin toxicity coz after taking digoxin he developed palpitation, vomiting, atrial fibrillation, and the most important is-he is taking hydrochlorothiazide which might have caused hypokalemia, and hypokalemia is responsible for digoxin toxicity. Really nice thinking. But the question is what is the most likely cause for his abdominal distension? Since digoxin toxicity doesn't cause abdominal distension, so we need to think again. This patient has atrial fibrillation. Could it be possible that atrial fibrillation--->embolism-->superior mesenteric artery-->mesenteric embolism? Is it possible? I am not sure, but not a bad guess anyway. Another possible cause is hypokalemia causing paralytic ileus. Use ur brain.

well hero i was not quite sure while i wrote this answer because in digoxin tixicity there is nausea vomitiong ,diarohea, and little cramp but not the distension and patient was started with verylittle dose of drug 0.125 mg tid but regarding other things he surely delvoped hypokalemia because the drug hydrochlorothiazide .
well sorry i was busy so could not read the massage on time.
well now i have read your option and from juns too.
well i am little unmature for the judgement so does mistake most of the time any way thanks for expaination