Shock With Acute Myocardial Dysfunction in Stercoral Colitis

BACKGROUND: Shock in sepsis is predominantly vasodilatory; however, concomitant myocardial dysfunction may result in superimposed cardiogenic shock and a mixed shock state. CASE SUMMARY: A 75-year-old man with Parkinson disease, severe constipation, and stercoral colitis presented with profound shock after an enema. Echocardiography showed new biventricular dysfunction with regional wall-motion abnormalities. Invasive hemodynamic assessment demonstrated elevated filling pressures, low cardiac index, and low systemic vascular resistance despite substantial vasoactive and inotropic support, consistent with a mixed vasodilatory and cardiogenic shock. He improved after antibiotics and vasoactive support, but manual disimpaction after stabilization was followed within minutes by recurrent/similar shock. REVIEW SUMMARY: This case illustrates a practical approach to mixed shock with acute myocardial dysfunction. Treatment of underlying infection should occur in parallel with characterization of the hemodynamic phenotype. Serial echocardiography and invasive hemodynamic assessment can identify concomitant vasodilatory and cardiogenic shock and guide circulatory support as shock physiology evolves. TAKE-HOME MESSAGES: Shock physiology is dynamic. In patients with sepsis, serial clinical, echocardiographic, and hemodynamic reassessment can identify concomitant cardiogenic shock and guide circulatory support.