Transcript Medical Grand Rounds Clinical Vignette October 3, 2007

Clinical Correlations
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Medical Grand Rounds
Clinical Vignette
October 8, 2008
Sabina Berezovskaya, M.D.
Chief Complaint
• 49 year old male presents with early
satiety for three months and one day of
red blood and clots mixed with stool one
week prior to presentation.
History of Present Illness
• He was in his usual state of health until three months
prior to admission when he began experiencing frequent
early satiety and subjective weight loss.
• One week prior to presentation patient noted bright red
blood per rectum with clots which spontaneously
resolved after one day.
• One day prior to admission, he had routine labs drawn at
his cardiology clinic appointment.
• He was recalled for admission when his hemoglobin
returned significantly decreased from his baseline.
Further history
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Past Medical History:
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GERD
Diabetes Mellitus Type II
Hypercholesterolemia
Hypertension
Coronary artery disease (CAD) with prior STEMI (10/07) requiring percutaneous
stenting of the RCA
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Past Surgical History: Denies
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Social History:
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Family History: Non-contributory
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Medications:
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– Prior history of alcohol abuse (20 beers per day). Last use 2 years ago
– No tobacco or illicit drug use
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Aspirin 81 mg daily
Clopidogrel 75mg daily
Metoprolol 50 mg twice a day
Lisinopril 20 mg daily
Simvastatin 40 mg daily
Metformin 1g twice a day
Pioglitazone 30 mg daily
Esomeprazole 40 mg daily
Allergies: no known drug allergies
Physical Exam
• General : Well nourished and well developed male; in no
acute distress
• Vital signs: T- 98º F BP: 99/75 HR: 62 RR: 18 O2 sat:
100% RA
– Orthostatics were negative
• Abdomen: mildly tender at the right lower quadrant
• Rectal: no masses or tenderness; black guaiac + stool
The physical exam was otherwise entirely normal.
Laboratory Findings
• WBC: 7.7, normal differential
• Hgb: 7.9 g/dl, MCV 65.6, RDW: 15.8
– Prior baseline hgb 13-14g/dl
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Platelets: 384
Iron: 16 mcg/dL (nl: 42-146)
TIBC: 462 mcg/dL (nl: 250-450)
Ferritin: 4.8 ng/mL (nl: 22-322)
• Basic metabolic panel, liver function tests,
amylase, lipase & coagulation profile were all
within normal limits
Imaging
• Chest x-ray: no cardiopulmonary disease
• EKG: normal sinus rhythm with q waves in
II,III, aVF; unchanged from prior baseline.
Working diagnosis
Lower Gastrointestinal Bleed
Colonoscopy
• A single sessile polyp measure 6mm in size was
found in the hepatic flexure.
• The polyp was removed with a hot snare
• There was a friable non-obstructing
circumferential tumor in the ascending colon
immediately distal to the IC valve
Colonoscopy
Pathologic Diagnosis
Poorly Differentiated Invasive Carcinoma
+ for Cytokeratin 20 and Neuron Specific
Enolase (NSE)
- for Cytokeratin 7, Synaptophysin or
Chromographin
Clinical Staging Evaluation
• Abdomen & Pelvis CT:
Ascending colon tumor with multiple
enlarged adjacent mesenteric lymph
nodes
• Chest CT:
No evidence for intrathoracic metastatic
disease
• CEA <0.5 (nl <=5)
Abdominal / Pelvic CT Scan
Hospital Course
• Patient was transfused with 1 Unit of packed
red blood cells and started on Iron
supplementation
• He remained hemodynamically stable and had
no recurrent episodes of bleeding
• Patient was evaluated by surgical consult and a
right hemicolectomy was scheduled
Final Diagnosis
Lower Gastrointestinal Bleed due to
Poorly Differentiated Adenocarcinoma
of the ascending colon and the hepatic
flexure