Surgical abdomen masked by metabolic crisis: fulminant ischemic colitis in severe diabetic ketoacidosis - a case report and literature review.

Background: Abdominal pain and gastrointestinal symptoms are common in diabetic ketoacidosis (DKA) and are generally reversible with metabolic correction. However, persistent or worsening abdominal findings should prompt concern for an underlying intra-abdominal emergency. Intestinal ischemia is an uncommon complication of severe hyperglycemic crisis in young patients but may progress rapidly to transmural necrosis due to profound hypovolemia and compromised microvascular perfusion. Case presentation: A 30-year-old woman with type 1 diabetes mellitus presented with a 3-day history of diarrhea, vomiting, and stupor following insulin omission. Laboratory evaluation demonstrated extreme hyperglycemia (1,869 mg/dL), severe metabolic acidosis (arterial pH 6.83; bicarbonate 2.2 mmol/L; anion gap 20.8 mmol/L), and acute kidney injury. She was managed for a mixed DKA and hyperosmolar hyperglycemic state with intravenous fluids, continuous insulin infusion, and electrolyte replacement. Although her anion gap narrowed, acidemia persisted, renal function deteriorated, and lactate levels increased. She subsequently developed hemodynamic instability requiring vasopressor support, along with progressive abdominal distension and rigidity. Non-contrast abdominal computed tomography revealed pneumatosis intestinalis extending from the ascending to the proximal transverse colon. She underwent emergency subtotal colectomy with end-loop ileostomy; histopathological examination confirmed transmural infarction of the ascending colon with subserosal abscess formation. Following intensive care management and continuous renal replacement therapy, she recovered and was discharged in stable condition. Conclusion: This case highlights a critical diagnostic challenge: apparent biochemical improvement during a hyperglycemic crisis, such as the narrowing of the anion gap, does not exclude evolving intestinal ischemia. Endocrinologists and critical care physicians must recognize that disproportionate or progressive abdominal signs require prompt imaging and early surgical consultation, even when contrast-enhanced studies are contraindicated.