Case presentation

A 37-year-old man presented to the emergency department with a one-day history of diffuse and constant abdominal pain. He indicated that it was secondary to intentional acetaminophen overdose with the intent of suicide. He also reported nausea and vomiting, which began after the consumption of the acetaminophen. He reported taking 30 tablets of acetaminophen, approximately 16,000 mg, around 11 p.m. the night before arrival to the emergency department at 10 a.m. In the emergency department, the patient did not report any use of alcohol. The patient had a past medical history of rhabdomyolysis secondary to cocaine ingestion, major depressive disorder, and obsessive-compulsive disorder, with past hospitalizations due to psychiatric reasons, including attempted suicide, and chronic asymptomatic Hepatitis C infection. On physical exam, the patient’s vital signs were: temperature 98.9F, blood pressure (BP) 131/91, heart rate (HR) 71, peripheral oxygen saturation (SpO2) 98%. The patient was without any acute distress, alert, and oriented with normal mental status. Cardiac, respiratory, and neurological exams were normal. The gastrointestinal exam revealed a soft and nondistended abdomen with generalized abdominal tenderness, with no guarding or rebound. No jaundice or asterixis was noted. Labs are described in Table 1. CT abdomen revealed acute colitis of the transverse, sigmoid colon, and rectum (Figure 1).

Laboratory Value | Day 0 | Day 1 | Day 3 | Day 5 | Day 7 | Day 9 | Reference Range
Hemoglobin (g/dL) | 12.7 | - | 13.5 | - | 12.9 | 15.2 | 13.5-7.5
White Blood Cell Count (×10³/µL) | 16.4 | 8.3 | 10.8 | 10.0 | 14.2 | 5.5 | 4.0-11.0
Platelet Count (×10³/µL) | 269 | - | 325 | 318 | 311 | 389 | 150-400
Blood Urea Nitrogen (mg/dL) | 16.0 | 13.0 | 4.0 | 5.0 | 6.0 | 11.0 | 7-20
Creatinine (mg/dL) | 0.90 | 0.80 | 0.60 | 0.60 | 0.60 | 0.60 | 0.7-1.3
Total Bilirubin (mg/dL) | 1.7 | 1.4 | 0.3 | 0.2 | 0.3 | 0.3 | 0.2-1.2
AST (U/L) | 81 | 49 | 30 | 25 | 24 | 25 | 10-40
ALT (U/L) | 28 | 23 | 22 | 23 | 24 | 21 | 7-56
Alkaline Phosphatase (U/L) | 78 | - | 73 | 70 | 66 | - | 44-147
INR | 1.15 | - | 0.92 | - | - | 1.21 | 0.8-1.2
Acetaminophen (µg/mL) | 108 | 54 | 10 | 10 | 10 | <10 | <10
Hepatitis C Antibody | Not Obtained | Reactive | - | - | - | - | Nonreactive

Figure 1: CT axial displaying colonic inflammation and fat stranding.

The patient was admitted to inpatient medicine for an intentional acetaminophen overdose. Gastroenterology was consulted because of abnormal liver enzymes, concern for acetaminophen-associated hepatotoxicity, and subsequent hematochezia with CT evidence of colitis. Toxicology/Poison Control guided the management of acetaminophen overdose while Gastroenterology evaluated the gastrointestinal manifestations. Gastroenterology saw the patient at 3 p.m. the day of his hospital admission. At the time, his acetaminophen level was 108 (ug/mL), roughly 14 hours after ingestion. During interview of the patient by the GI team, the patient disclosed administering 1.5 L of vodka in his rectum the day prior before ingesting acetaminophen. He reported bloody, profuse, watery diarrhea that started immediately after the vodka administration. He had about six to eight loose bowel movements mixed with blood in total since the administration of the ethanol enema. After this disclosure, a colonoscopy was planned. Colonoscopy identified erythema and erosions in the rectal-sigmoid region, consistent with colitis (Figure 2). CT demonstrated inflammatory changes involving the transverse, sigmoid colon, and rectum, whereas colonoscopy identified the most prominent mucosal abnormalities within the rectosigmoid colon. This discrepancy likely reflects the greater sensitivity of CT for detecting mural edema over a broader segment of bowel, whereas endoscopy directly visualizes mucosal injury, which may be most pronounced distally following rectal ethanol administration. Stool infectious testing was not performed because the clinical presentation was highly consistent with chemical colitis following a toxic exposure.

Figure 2: Colonoscopic images of mucosal inflammation of the rectum.Colonoscopy demonstrated continuous erythematous and friable mucosa with superficial erosions involving the rectum and sigmoid colon. No deep ulcerations or transmural necrosis were identified. Biopsies were not obtained because the endoscopic appearance was considered diagnostic for acute chemical injury and biopsy was unlikely to alter management.

The patient was initially admitted for acetaminophen overdose and started on N-acetyl cysteine (NAC) protocol [7]. After identifying the ethanol enema, the treatment plan was extended to include treatment for colitis. Poison Control was contacted immediately and recommended intravenous N-acetylcysteine therapy according to established acetaminophen overdose protocols. Intravenous N-acetylcysteine was initiated using the standard 21-hour protocol because the patient presented approximately 11 hours after ingestion with a toxic acetaminophen concentration of 108 μg/mL. Therapy was continued with serial monitoring of acetaminophen concentrations, liver function tests, and international normalized ratio (INR) until acetaminophen levels became undetectable and hepatic function remained stable. The patient was placed on 1:1 observation and was compliant with treatment. Antibiotics were not indicated. The patient’s liver enzymes continued to improve with a normal INR throughout his hospital stay. Transfer to a liver transplant center was initially discussed because of the potentially delayed evolution of acetaminophen-induced liver injury after a large intentional overdose. However, the patient's INR remained normal, bilirubin and transaminases improved, and he never met criteria for acute liver failure or transplant evaluation. For the patient's bloody diarrhea, intravenous fluid was administered, and oral intake was encouraged. Over the course of the hospital stay, the patient reported resolution of abdominal pain after five days and resolution of diarrhea after nine days. He was signed off the gastroenterology service and transferred to inpatient psychiatric care for two weeks. At psychiatric discharge, gastrointestinal symptoms had resolved.

Hospital Day | Event
Day -1 | 1.5 L vodka enema
Later | 16 g acetaminophen ingestion
Day 0 | ED presentation
Day 0 | NAC initiated
Day 0 | Poison Control consulted
Day 1 | Colonoscopy
Day 5 | Abdominal pain resolved
Day 9 | Diarrhea resolved
Day 9 | Transferred to psychiatry