Crohn’s Disease Patient Requires Amputation Of All Extremities Following Colectomy

ByWendy Ketner, M.D.

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Updated onApril 11, 2019

This case involves a 33-year-old male patient with Crohn’s disease with a history of a hemicolectomy. For 2 years following the procedure, the patient tried multiple regiments to control his symptoms but continued to have 10-15 stool per day. A TPMT test was done and the results came back normal. The patient was then prescribed 50mg of 6-MP daily by his gastroenterologist. A week after his first dose, the patient presented to the emergency room with altered mental status, shortness of breath, and tongue swelling. On physical exam, the patient exhibited a patent airway. He was treated with epinephrine, pepcid, and solumedrol. He was then intubated for airway protection due to his increasing altered mental status. The patient quickly developed severe acidosis and acute kidney injury and was given fluids and bicarb. In spite of this treatment, the patient coded twice in the emergency room. He remained in the ICU on pressors during his first 24 hours of admission and his systolic blood pressure remained very low. The patient’s extremities began to feel cold and mottled with decreased peripheral pulses and necrotic digits. The patient eventually required amputations of all extremities.

Question(s) For Expert Witness

1. How often do you treat angioedema?

2. Are there signs and symptoms for which you treat with epinephrine or for which you might not?

3. When a patient has a history and presents with symptoms and labs like the one in the case, what are you most concerned about?

Expert Witness Response E-097490

inline imageI treat approximately 1-2 cases per month but it can be variable. For ACE inhibitor induced angioedema, it seems to have a seasonal variation. As far as histaminergic/allergic angioedema, it is less common. Obviously, any signs of anaphylaxis, epinephrine is indicated - there are no strict contra indications (unless the patient has a documented allergy to perhaps the diluent used for the epinephrine administered. As far as angioedema, it all depends on the etiology. For bradykinin induced angioedema (ace inhibitor induced or hereditary angioedema), there is no role for the most part. For histaminergic/anaphylactic angioedema, it is first line therapy. Obviously, as an emergency physician, the airway is always the first priority followed by breathing and circulation (i.e. the "ABC's"). Second, is determining a reversible cause. In this case, I would assume a rapid fingerstick blood sugar was performed simultaneously as the ABC's are being addressed. This is basic emergency medicine practice. For if the glucose was low, this could potentially explain the patients altered mental status and if addressed quickly, might have averted the need for intubation.

About the author

Wendy Ketner, M.D.

Wendy Ketner, M.D.

Dr. Wendy Ketner is a distinguished medical professional with a comprehensive background in surgery and medical research. Currently serving as the Senior Vice President of Medical Affairs at the Expert Institute, she plays a pivotal role in overseeing the organization's most important client relationships. Dr. Ketner's extensive surgical training was completed at Mount Sinai Beth Israel, where she gained hands-on experience in various general surgery procedures, including hernia repairs, cholecystectomies, appendectomies, mastectomies for breast cancer, breast reconstruction, surgical oncology, vascular surgery, and colorectal surgery. She also provided care in the surgical intensive care unit.

Her research interests have focused on post-mastectomy reconstruction and the surgical treatment of gastric cancer, including co-authoring a textbook chapter on the subject. Additionally, she has contributed to research on the percutaneous delivery of stem cells following myocardial infarction.

Dr. Ketner's educational background includes a Bachelor's degree from Yale University in Latin American Studies and a Doctor of Medicine (M.D.) from SUNY Downstate College of Medicine. Moreover, she is a member of the Board of Advisors for Opollo Technologies, a fintech healthcare AI company, contributing her medical expertise to enhance healthcare technology solutions. Her role at Expert Institute involves leveraging her medical knowledge to provide insights into legal cases, underscoring her unique blend of medical and legal acumen.

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