LAUSR

Acute abdominal pain represents 5-10% of the cases presenting at the emergency department1. A severe cause of acute abdominal pain is a gastrointestinal perforation, with mortality rate 30–50%2. This case describes a care-avoiding psychiatric patient with a history of psychotic dysregulation and suspected substance abuse, now presenting with severe abdominal pain. A 42-year-old woman with a history as described above, presented at the emergency department with severe and increasing abdominal pain, vomiting, weight loss and deterioration of physical condition since a few weeks. Physical examination showed no signs of sepsis. A CT scan showed free subdiafragmatic gas, signs of peritonitis, and formation of abscesses in the lower abdomen, most suspicious for gastrointestinal perforation. Due to psychiatric burden, the patient was reluctant and anxious towards surgery. Eventually consensus was achieved to perform radiologically guided and transrectal drainage of the abscesses in combination with antibiotic treatment. This treatment seemed successfull and the patient could be discharged after one week. After three weeks, the patient was readmitted due to increasing pain caused by extensive subcutaneous abscesses in the lower abdominal wall, inguinal region, and pubic region. Incision and drainage was performed. Due to absence of clinical improvement, increase of necrosis, and persistent bleeding a second debridement was necessary. Considering the psychiatric burden in combination with previously present lethargy, cachexia, and poor general condition, a multidisciplinary approach was used to firstly investigate the origin of the suspected perforation, and secondly to rule out potentially contributing underlying health problems. Additional investigations were inconclusive. However, colonoscopy only reached up to the sigmoid. Based on the clinical presentation vitamin deficiencies were suspected, especially vitamin C deficit. Measures were taken to optimize nutritional intake, as well as multivitamin suppletion was provided. Eventually, significant clinical progress was observed. The wounds healed and the patients overall condition improved. The patient could be discharged. After a few weeks laboratory testing revealed a vitamin C deficiency. Initially, considering the severity of the case, surgical intervention seemed the appropriate treatment3. However, conservative treatment was chosen. On the one hand, this strategy resulted in a trusted physician-patient relationship and therefore a well collaborative patient. On the other hand, this decision could have contributed to the appearance of complications such as subcutaneous abscesses and therefore further deterioration of physical condition and prolonged admission. Furthermore, since surgery was not performed, until now the cause stays unknown, which made management and decision-making during admission highly complicated. Psychiatric care-avoiding patients have an increased risk on morbidity and are more likely to suffer from undiagnosed somatic health problems4. Prevalence of vitamin C deficiency in the general population appears to be remakably high, namely 7.1%, with an even higher risk in psychiatric patients5. It was therefore contributing to empirically start suppletion. Since test results only appear after several weeks, it is advisable to start suppletion when deficiencies are suspected. In conclusion, however the management in this case could be critisized, the patient centered and multidisciplinary approach lead to curation.