Chronic Diarrhea (Small Group Session 19) Flashcards
A 20 year old man has a 7 wk history of diarrhea (6-8 BM/day), which has now become bloody. He awakens at least one time per night to run to the bathroom. On occasion he will only pass blood and mucous. Pt complains of cramping, nausea and tenesmus. Mom says he has lost weight. Pt is otherwise healthy. Conjunctiva are pale and blue. Abdomen is flat and non-distended, normal bowel sounds. Tenderness in LLQ. DRE reveals mild tenderness in rectum and boggy feeling of rectal mucosa as well as scant blood. Three raised erythematous patches on the anterior aspect of each shin. BP 110/60 HR 94 T 38.0.
Additional Info:
- Recent trip to Guatemala where mom and sister also developed bloody diarrhea but has resolved. Pt remains ill.
- Antibiotics two months ago after wisdom teeth extraction.
- No current medications or NSAIDs.
- Half a pack/day smoker since age 15 but quit three months ago.
- Low back pain; pt thinks due to working out.
What is your differential diagnosis?
The differential diagnosis for this patient is:
- IBD; Ulcerative Colitis or Crohn’s
- Traveller’s Diarrhea
- Bacterial: E. coli (ETEC), Campylobacter, Shigella, Salmonella, Vibrio
- Viral: Norovirus, rotavirus
- Protozoa (rare): Giardia, E. histolytica 3. C. difficile diarrhea
A 20 year old man has a 7 wk history of diarrhea (6-8 BM/day), which has now become bloody. He awakens at least one time per night to run to the bathroom. On occasion he will only pass blood and mucous. Pt complains of cramping, nausea and tenesmus. Mom says he has lost weight. Pt is otherwise healthy. Conjunctive are pale and blue. Abdomen is flat and non-distended, normal bowel sounds. Tenderness in LLQ. DRE reveals mild tenderness in rectum and boggy feeling of rectal mucosa as well as scant blood. Three raised erythematous patches on the anterior aspect of each shin. BP 110/60 HR 94 T 38.0.
What physical examination features would specifically point to a diagnosis of iron deficiency anemia?
Clinical Features of Iron Deficiency Anemia:
- Pallor
- Angular stomatitis
- Koilonychia
- Blue sclera
- Shortness of breath
- Glossitis
- Pica
A 20 year old man has a 7 wk history of diarrhea (6-8 BM/day), which has now become bloody. He awakens at least one time per night to run to the bathroom. On occasion he will only pass blood and mucous. Pt complains of cramping, nausea and tenesmus. Mom says he has lost weight. Pt is otherwise healthy. Conjunctive are pale and blue. Abdomen is flat and non-distended, normal bowel sounds. Tenderness in LLQ. DRE reveals mild tenderness in rectum and boggy feeling of rectal mucosa as well as scant blood. Three raised erythematous patches on the anterior aspect of each shin. Patient also describes back pain. BP 110/60 HR 94 T 38.0.
What is the differential diagnosis for thrombocytosis in this case?
Differential Diagnosis for Thrombocytosis:
- IBD
- Celiac Disease
- Rheumatic disorders
- Infectious cause of reactive thrombocytosis
Reactive Thrombocytosis Differential Diagnosis
- Infectious: Acute or Chronic
- Inflammatory: IBD, Rheumatic disorders, Celiac disease
- Tissue Damage: Post-op surgery, trauma, burns
- Non malignant hematologic conditions: rebound effect following treatment of ITP, rebound effect following ETOH induced thrombocytopenia
- Other: post-splenectomy or hyposplenic states, non-hematologic malignancy, iron deficiency anemia
- Thrombocytosis scheme: pg. 60 Blackbook
A 20 year old man has a 7 wk history of diarrhea (6-8 BM/day), which has now become bloody. He awakens at least one time per night to run to the bathroom. On occasion he will only pass blood and mucous. Pt complains of cramping, nausea and tenesmus. Mom says he has lost weight. Pt is otherwise healthy. Conjunctive are pale and blue. Abdomen is flat and non-distended, normal bowel sounds. Tenderness in LLQ. DRE reveals mild tenderness in rectum and boggy feeling of rectal mucosa as well as scant blood. Three raised erythematous patches on the anterior aspect of each shin. Patient also describes back pain. BP 110/60 HR 94 T 38.0. Dr. Coderre performs a flexible sigmoidoscopy. The scope reveals inflammation beginning in the rectum at the anal verge and extending to the splenic flexure. There is erythema, edema, and granularity to the mucosa. It appears friable and bleeds in areas when it is brushed by the sigmoidoscope.
What is the diagnosis?
Ulcerative colitis
A 20 year old man has a 7 wk history of diarrhea (6-8 BM/day), which has now become bloody. He awakens at least one time per night to run to the bathroom. On occasion he will only pass blood and mucous. Pt complains of cramping, nausea and tenesmus. Mom says he has lost weight. Pt is otherwise healthy. Conjunctive are pale and blue. Abdomen is flat and non-distended, normal bowel sounds. Tenderness in LLQ. DRE reveals mild tenderness in rectum and boggy feeling of rectal mucosa as well as scant blood. There are three raised erythematous patches on the anterior aspect of each shin. Patient also describes back pain. BP 110/60 HR 94 T 38.0. Dr. Coderre performs a flexible sigmoidoscopy. The scope reveals inflammation beginning in the rectum at the anal verge and extending to the splenic flexure. There is erythema, edema, and granularity to the mucosa. It appears friable and bleeds in areas when it is brushed by the sigmoidoscope.
What are the treatment options for this patient?
Therapy in escalating order (first line to last resort):
- 5-ASA (oral or topical): Sulfasalazine, Asacol, Pentasa, Salofalk -Corticosteroids (oral or IV): oral prednisone, IV solumedrol/solucortef
- Immune modulators: Azathoprine (Imuran) -Anti-TNF Therapy: IV cyclosporine, Infliximab (Remicade), Adalimumab (Humira), Certolizumab (Simponi)
- Biologics -Surgery: proctocolectomy with ileostomy, proctocolectomy with ileal-anal pouch
Compare and contrast iron deficiency anemia and anemia of chronic disease using the following table.
Outline the differences between Ulcerative Colitis and Crohn’s disease in terms of the following features:
- Anatomic location
- Distribution
- Fistulae or abscess
- Strictures
- Current Smoker
- Blood diarrhea
- Perianal disease
How does Ulcerative Colitis appear on endoscope in comparison to Crohn’s disease? Describe using the following features.
- Distribution
- Inflammation
- Ulceration
- Colonic lumen
What are the appropriate investigations in a patient presenting with bloody diarrhea?
Investigations in pts. presenting with bloody diarrhea:
- Bloodwork and stool cultures for C+S, O+P and C. difficile toxin
- Hemoglobin
- MCV
- WBC
- Platelets
- CRP
- Electrolytes
- Creatinine
- Albumin
- Ferritin
- Iron studies
- Scope: sigmoidoscopy, colonoscopy
What is the name of this endoscopic finding? What disease is it associated with?
This is called “cobblestoning” and is associated with Crohn’s disease.
This is a photo from a colonoscopy of a pt. that presented with symptoms of urgency needing to get to the bathroom, bloody diarrhea and tenesmus. What is your diagnosis?
This is severe Ulcerative Colitis.
What treatment modalities are available for pts. with Ulcerative Colitis?
UC Treatment
- 5-ASA (oral or topical)
- Corticosteroids (oral or IV)
- Immunomodulators
- IV cyclosporine
- Infliximab (Remicade), Adalimumab (Humira), Certolizumab (Simponi)
- Surgery
- Proctocolectomy with ileostomy
- Proctocolectomy with ileal-anal pouch
What treatment modalities are available for pts with Crohn’s disease?
Treatment of Crohn’s Disease
- Corticosteroids (topically acting, oral or IV)
- Immunomodulators: azathioprine, methotrexate
- Antibiotics
- Infliximab (remicade), Adalimumab (Humira)
- Surgery
- Stricturoplasties
- Segmental resection
Compare and contrast the characteristics of small bowel vs. large bowel diarrhea in regards to the following:
- Volume
- Frequency
- Blood
- Pain-Location
- Rectal Symptoms
- Steatorrhea
- Weight Loss
- Effect of Fasting
- Nutritional Deficiency
