Gupta, Riya

ABSTRACT Levator ani syndrome (LAS) explains up to 7.4% of anorectal pain cases. Classic symptoms include rectal pain or pressure with sitting. We present 2 patients, ages 32 and 25 years, presenting initially with “diarrhea” and perianal hyperhidrosis. History revealed rectal discomfort, tenesmus, urgency, and sensation of incomplete evacuation. Puborectalis tenderness was present on digital rectal examination. Therapies were tailored to each patient, including pelvic floor physical therapy with biofeedback, bowel regulation, rectal diazepam, and ileostomy. These presentations offer insights into potential pathophysiological mechanisms in LAS and highlight the importance of considering LAS in non-pain presentations.

Euglyceamic diabetic ketoacidosis (EuDKA) is an uncommon but serious diabetes mellitus complication associated with risk factors such as fasting, surgery, pregnancy and, more recently, the use of sodium–glucose cotransporter-2 inhibitors (SGLT2i). This case is of a woman with type 2 diabetes and hypertension in her 50s who underwent an incarcerated umbilical hernia repair and abdominoplasty. Two days after discharge, she was readmitted with nausea, vomiting, loss of appetite, low-grade fever and breathing difficulty. Preoperatively, her diabetes management included an SGLT2i. She was diagnosed with EuDKA with high anion gap metabolic acidosis, a medical emergency similar to diabetic ketoacidosis. The normal blood glucose levels in EuDKA can mask the condition, which poses a conundrum for physicians in the emergency department/intensive care units as it may delay diagnosis and treatment, worsening the outcomes. To mitigate this risk, SGLT2i should be stopped 3–4 days before planned surgery with appropriate adjustments to the insulin regimen.