A 55-year-old female with a past medical history of CKD, acute kidney injury (AKI) superimposed on CKD, diabetes mellitus type 2 with diabetic neuropathy, pancreatitis, chronic obstructive pulmonary disease, tubal ligation, rectocele, and peripheral vascular disease (PVD) presented to the Emergency Department (ED) with vomiting, diarrhea, and weakness for the prior three days. She also complained of mild abdominal pain (8/10 in severity) that was non-radiating in the emergency department, and had one episode of emesis during triage. She stated that she had multiple episodes of vomiting every day over the previous three days and was unable to tolerate any oral food or drinks, including water, as a result. The patient denied seeing any red blood in her vomit but stated that sometimes it is a dark brown color. She endorsed recent dry heaving because there was no food left in her system. She stated that the abdominal pain was located in the epigastric region and denied any trigger for the pain. The patient was an active tobacco user, smoking four packs per day, and endorsed smoking cannabis daily to help her relax.

During the first day of admission, the patient stated that she had a recent change to her medication; she was on tirzepatide once per week before stopping for two months. She restarted her medication recently on June 4th, 2025, at 2.5 mg, and was increased to 5 mg four weeks later, and was then increased again to 7.5 mg in August; her symptoms started two days after this last adjustment. Tirzepatide and empagliflozin were held due to these symptoms and were replaced with a weight-based insulin regimen for glycemic control. The patient denied any fever, chest pain, headache, shortness of breath, palpitations, melena, hematochezia, or any numbness in her extremities. She also denied any recent travel or antibiotic use. On the physical exam, epigastric tenderness was noted as well as a negative guaiac test. Vital signs included a temperature of 99℉, tachycardic pulse of 128 beats per minute (bpm), respiratory rate of 14 breaths per minute, oxygen saturation of 96%, and an elevated blood pressure of 184/89 mmHg. Gastroenteritis was suspected, as well as further evaluation for associated metabolic derangements vs dehydration. Sepsis workup was initiated, and labs were relevant for elevated troponin (59.1) and lactate (3.6). CTAP showed wall thickening of multiple small bowel loops and colon, suggestive of enterocolitis. Urine toxicology was positive for marijuana. In the ED, she received 3 L of intravenous (IV) fluids, metoclopramide 10 mg, and ondansetron 4 mg. 

She was planned to be admitted to telemetry for continuation of IV hydration, antibiotics, and serial abdominal exams. She was admitted for severe sepsis secondary to complicated urinary tract infection (UTI) vs enterocolitis. On the first day of admission, she was given ciprofloxacin 400 mg IV twice a day (BID) and metronidazole 500 mg IV thrice a day (TID) for urinary tract infection (UTI) and enterocolitis. Due to the positive troponin, a statin loading dose of aspirin (325 mg) was given with subsequent aspirin 81 mg daily. Cardiology was consulted, and an echocardiogram was performed to rule out cardiac pathology. Because the patient had AKI superimposed on CKD, fluid hydration was given. CT of the abdomen and pelvis showed wall thickening of multiple small bowel loops and colon, suggestive of enterocolitis (Figure 1).

The next day, urine toxicology was positive for tetrahydrocannabinol (THC), consistent with cannabis use. She continued to have poor oral intake and was mostly on a fluid diet. She was also started on ondansetron every four hours as needed due to persistent nausea. Doppler was performed due to chronic peripheral vascular disease (PVD) and showed >50% stenosis of the distal peroneal artery. The morning of hospital day three, she reported one episode of vomiting with low appetite. In the afternoon, she was able to tolerate clear liquids and did not have any more episodes of vomiting. 

On day four of admission, during rounds, the patient admitted to feeling worse overnight. She endorsed some odynophagia, dyspnea, a cough with ambulation, and reported two episodes of soft, black, large bowel movements overnight and in the morning. She denied any chest pain or palpitations, although tachycardia was noted on telemetry monitoring. Heparin, aspirin, and clopidogrel were held due to the bleeding, and ondansetron was changed to cefazolin and metronidazole to complete a seven-day course of antibiotics. Transthoracic echocardiogram results came back showing a normal left ventricular ejection fraction, but did indicate diastolic dysfunction. Cardiology recommended no acute intervention at that time. Due to the dyspnea and tachycardia, D-dimers were ordered and came back positive at 947 ng/mL. Venous duplex doppler of the bilateral lower extremities was ordered with a ventilation-perfusion (VQ) scan. 

Anticoagulation was held at that point and reassessed after the venous doppler came back negative and the VQ scan resulted in a low probability of a pulmonary embolism. During the 5th day of hospitalization, she reported some melena during the previous overnight; the fecal occult bleeding test was positive. She also said she had some dyspnea and generalized weakness, but did not have any vomiting or throat pain. Lactic acidosis had also improved from 3.6 to 1.7. 

On her 6th and last day of hospitalization, she reported no nausea, vomiting, epigastric discomfort, or melena for the past 12 hours. Her shortness of breath resolved, and she was without coughing. Labs such as complete blood count (CBC), comprehensive metabolic panel (CMP), lipase, procalcitonin, and lactic acid were trending in the right direction, and she was able to tolerate food without any pain or difficulty swallowing (Tables 1, 2). Cardiology and gastroenterology cleared the patient for discharge, and she was discharged on insulin glargine, amlodipine, sucralfate, protonix, and ReLion NovoLog® flexpen, and followed up in a week with the medicine clinic. She was also scheduled to follow up with outpatient gastroenterology, nephrology, and cardiology appointments