S3924 Hypertensive Emergency: Moving Fast to Correct Slow Transit Constipation

Introduction: Hypertensive emergency is a life-threatening condition defined by severe hypertension and evidence of end-organ damage. Early recognition and initiation of timely management are necessary to reduce significant morbidity and mortality often associated with its presentation. Here, we discuss a unique case of hypertensive emergency due to acute-on-chronic constipation. Case Description/Methods: A 69-year-old man with hyperlipidemia and diabetes presented with 4 days of diffuse, progressive abdominal pain, nausea, and vomiting. On initial evaluation, his vital signs were notable for new-onset blood pressure elevation to 185/111 mmHg. Despite treatment with oral antihypertensive therapy and intravenous morphine, his symptoms persisted with worsening systolic pressures greater than 200 mmHg. The remainder of his examination was within normal limits, aside from notable tenderness to palpation over his lower abdomen. Laboratory testing revealed elevated high-sensitivity troponin (147 ng/L) and lactic acid (2.7 mmol/L), but blood counts, chemistries, renal and hepatic function, and index EKG were normal. Abdominal X-ray revealed a large stool burden throughout the colon and rectum with gaseous distention of the transverse colon, concerning for fecal impaction. Computed tomography angiography of the abdomen revealed neither acute vascular pathology nor evidence of bowel ischemia, but was notable for a large stool burden in the distal ascending colon without evidence of obstruction. He was subsequently started on continuous intravenous nicardipine and admitted to the cardiac intensive care unit for hypertensive emergency. For his severe constipation, polyethylene glycol, senna, lactulose, and bisacodyl suppositories were administered. Following a large volume bowel movement, he had complete resolution of his abdominal pain and blood pressure normalization. Serial troponins peaked at 185 ng/L and EKGs in parallel were without ischemic change. He was successfully discharged home on hospital day 3 with a daily bowel regimen and without the need for antihypertensive medications. Discussion: Constipation is a common cause of abdominal discomfort, and severe constipation can precipitate or exacerbate existing hypertension through mechanisms such as increased sympathetic activation due to pain. In cases such as this, it is important to consider this mechanism to provide timely management and attempt to reduce the morbidity and mortality associated with hypertensive emergencies.