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A man with a murmur requiring nutritional support
  1. S D Hearinga,
  2. I S Shawb,
  3. A Dayc,
  4. C S J Proberta
  1. aBristol Royal Infirmary, Bristol, UK: University Division of Medicine, bDepartment of Gastroenterology, cDepartment of Chemical Pathology
  1. Dr Christopher S J Probert, University Division of Medicine, Bristol Royal Infirmary, Bristol BS2 8HW, UKc.s.j.probert{at}bristol.ac.uk

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Answers on p 544.

A 52 year old man complained of severe abdominal pain of 24 hours' duration. He had had two episodes of bloody diarrhoea in the past six hours. Medical history was unremarkable. On examination he was systemically unwell, pyrexial (37.5°C), and was noted to have several splinter haemorrhages in his fingernails. Cardiovascular examination revealed a tachycardia (120 beats/min), an irregularly irregular pulse, blood pressure 100/80 mm Hg, and a diastolic murmur loudest at the apex. Abdominal examination revealed generalised tenderness with guarding in the lower abdomen. Initial investigations were as follows: haemoglobin concentration 113 g/l, white cell count 21 × 109/l, platelet count 550 × 109/l, serum sodium 134 mmol/l, potassium 3.4 mmol/l, urea 9.2 mmol/l, creatinine 102 μmol/l, arterial pH 7.22, and bicarbonate 14 mmol/l.

At laparotomy a large amount of small and large bowel was resected, leaving 20 cm ofjejunum, and a jejuno-transverse colonic anastomosis was performed.

Three months after surgery the patient was admitted with severe dehydration, anuria, and carpopedal spasm. His serum sodium concentration was 127 mmol/l, potassium 3.3 mmol/l, urea 58 mmol/l, and creatinine 403 μmol/l.

Questions

(1)
At presentation what diagnosis would you consider in this patient and how does this relate to the findings on examination of the cardiovascular system?
(2)
How are feeding and fluid requirements assessed in patients who have undergone intestinal resections and what plans should be made for nutritional support for this patient after laparotomy?
(3)
What has happened to the patient three months after surgery and what caused the carpopedal spasm?

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