Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Rennie Rhee MD, PGY-2
January 13, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 51-year-old man presents with
bloody diarrhea for 6 months.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient was in his usual state of health until 6 months
prior to admission, when he began to experience fever and
bloody diarrhea.
• He would experience 10-15 episodes of diarrhea per day
with increasing amount of blood clots noted in his stool.
• At that time, the patient initially presented to the emergency
room and an abdominal CT demonstrated pancolitis.
• The patient was given presumptive diagnosis of infectious
enterocolitis and discharged home on antibiotics.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Two weeks later, the patient presented in clinic reporting
persistence of his diarrhea.
• Colonoscopy was performed showing patchy erythematous
mucosa of the colon.
• Biopsy demonstrated a slight increase of lymphoplasmacytic
infiltrate from terminal ileum to the sigmoid colon, but mature
glands with little crypt distortion and mature globlet cells.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• Given the unclear etiology of his diarrhea, the patient
was given a trial of loperamide, but without relief.
• He was later given a trial of mesalamine for possible
ulcerative colitis, and this provided marked improvement.
• 5 days prior to admission, however, the patient
experienced recurrence of his frequent episodes of
bloody diarrhea, abdominal pain, and rectal burning.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• None
Past Surgical History
• None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Family History
• Father: Myocardial
infarction at age 68
Social History
• Smoker, 40 pack-years
• Denies alcohol use
• Denies illicit drug use
Outpatient Medications
Mesalamine 800mg three times daily
Allergies: Penicillin (anaphylaxis)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: Well-appearing middle-aged man, in no acute distress
Vitals: T 102.8F, BP 118/69, HR 91, RR 16
O2 saturation: 97% on room air
Abdominal: Soft, distended, normal bowel sounds, left lower
quadrant pain on light and deep palpation
The remainder of the physical exam was normal.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Initial Studies
• CBC:
• Hemoglobin 11.2 g/dL, Hematocrit 34%
• The remainder was within normal limits
• Basic Metabolic Panel: Within normal limits
• Hepatic Panel: Within normal limits
• C-reactive protein: 94 mg/L (0.215 – 3.0 mg/L)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging
Abdomen and Pelvis CT:
• Colonic inflammatory changes involving mid
transverse colon to rectum
• Interval decrease in rectosigmoid inflammation
• Abdominal lymph nodes measuring up to 1.3 cm
in right lower quadrant, most likely reactive
• Dilated appendix
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Acute Exacerbation of Ulcerative Colitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• The patient was started on prednisone and his
mesalamine dose was increased. Mesalamine enemas
were also initiated.
• Ciprofloxacin and metronidazole were empirically
started due to concern for acute appendicitis.
• General Surgery recommended no surgical intervention.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Hospital Course
• During his hospitalization, the colonoscopy was
repeated due to the original atypical biopsy results.
• New biopsies revealed chronic active colitis with
crypt distortion, cryptitis, and crypt abscesses.
•The patient’s symptoms slowly improved and he
was discharged in stable condition.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Ulcerative Colitis
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS