A Woman With Dizziness and Shoulder Pain After Colonoscopy
Saad A. Shebrain, MD; Patrick Knight, MD
July 31, 2020
Editor’s Note: The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a Case Challenge, please contact us.
A 65-year-old woman with a prior history of a cesarean delivery underwent a routine outpatient screening colonoscopy that was reported to be slightly difficult. No polypectomy was performed during the procedure.
Twelve hours later, the patient started experiencing upper abdominal pain and left-shoulder discomfort. On postprocedure day 1, she developed dizziness and was taken to the emergency department at a local hospital for evaluation.
News about associations with other serious conditions and important risk factors helped make sleep apnea this week’s top trending clinical topic. Results of a new study indicate that patients who undergo major noncardiac surgery and have undiagnosed obstructive sleep apnea (OSA) may be at increased risk for cardiovascular events. Patients with severe OSA experienced a composite of myocardial injury, cardiac death, congestive heart failure, thromboembolism, atrial fibrillation, and stroke at higher rates than those with moderate, mild, or no OSA. Although further studies are needed to assess strategies for possible intervention, the results suggest that preoperative screening for OSA may help identify patients at greater risk for complications.
Beyond cardiovascular concerns, a new study suggests that OSA may play a role in tau accumulation in the brain, which increases the risk for Alzheimer disease. Cognitively normal older adults with OSA were found to have an elevated tau PET signal in the entorhinal cortex. Participants with OSA were found to have an average of 4.5% higher levels of tau in this region. Further investigation is needed to determine whether treatment of OSA may prevent or impair the accumulation of tau or whether increased tau levels predispose to OSA in elderly patients.
OSA may also be a significant contributor to fatigue in individuals with multiple sclerosis (MS). Fatigue is among the most common and disabling symptoms in MS. The possibility that undiagnosed OSA may be a major contributor could be an avenue to alleviating the severity of fatigue. Of course, part of the problem is that OSA remains difficult to diagnose. As a recent commentary explained, some criteria used for diagnosis may not be helpful and may actually further complicate assessment of the condition. Given the potential associations of OSA with various serious conditions, discussion about how best to diagnose and treat it is likely to keep this subject trending.