Case Presentation: A 77-year-old man presented with one week of episodic pre-syncope. The symptoms were often associated with sitting up in the wheelchair. His past medical history was notable for a cervical spine injury after a bike accident complicated by quadriplegia, as well as neurogenic bladder and bowel dysfunction. Review of Systems was positive for constipation.On admission, he was found to have intermittent supine hypertension with systolic pressure in the 200s mmHg lasting a few minutes. Orthostatic hypotension with the systolic blood pressure dropping to 90s mmHg upon sitting was also observed. His last known documented orthostatic blood pressure was negative one year ago in the setting of outpatient physical therapy. His physical exam was notable for a distended and tympanic abdomen. Workup revealed diffuse ileus with colonic dilatation measuring up to 8.1 cm on the abdominal X-ray. Post-void residual was within acceptable range. Upon further interview, the patient recalled similar episodes of blood pressure variation associated with presyncopal symptoms during past screening colonoscopies in the setting of scope passage and insufflation. Gentle bowel regimens with osmotic agents were started to help increase bowel movements with good effect. By hospital day 5, there were no further recordings of drastic blood pressure variation. His symptoms also completely resolved. The patient was discharged with close follow up with his neurologist.
Discussion: First described in 1917, autonomic dysreflexia is a disorder characterized by exaggerated sympathetic responses in patients with spinal cord injuries above T6. Patients often present with sudden, severe hypertension when confronted with noxious stimuli below the level of injury, most commonly bladder and bowel distension. Patients can have a wide range of symptoms, from being asymptomatic to having headache, nausea, diaphoresis, thermodysregulation, confusion, or even stroke. Associated orthostatic hypotension, as seen in our patient, is also common. Pathophysiology underlying the dysregulation of the sympathetic nervous system leading to uncoordinated autonomic response is complex and responsible for the diverse consequences. Susceptible patients are said to have higher risk of developing dysreflexia with higher level and complete spinal cord injury. In this patient population, it is important to recognize these events of autonomic dysregulation and investigate the inciting causes. Bowel related triggers are the second most common cause after bladder distension. Dysreflexia causing severe hypertension and seizure has also been described in a patient with spinal cord injury during colonoscopy. In these patients, experts recommend avoidance of large-volume enemas and vigorous manual or digital rectal stimulation.
Conclusions: 1. Autonomic dysreflexia is a potentially lethal disorder and must be considered in patients with spinal cord injury above T6 who present with severe hypertension or orthostatic hypotension. 2. It is important to investigate bladder or bowel distension as potential triggers of dysreflexia.