3rd Year Surgery Clinico-Pathological Conference

August 12, 2009

Francis Angelo Gilbuena, Diane Charleen T. Gochioco, Michael Jeffrey Gonzales, Ryan P. Haviland, Kevin

Matthew R. Henson, Ritchel Hidalgo, Melady D. Imperial, Monique Lucia A. Jardin, Kelechi Sunny Jigo,

Chiela L. Jumalon, Clarissa Anne C. KawGroup 8, Section A

Outline of Presentation

• Identifying Data and Chief Complaint• History of Present Illness• Past Medical History• Family History/ Social History• Course in the Wards• Laboratory Results• Imaging Results• Clinical Impression• Differential Diagnosis• Diagnostic and Therapeutic Plan

Identifying Data and Chief Complaint

• 62 year old male, retired automotive mechanic from Cubao, Quezon City consulting for the 1st time at UERMMMC for a complaint of Hematochezia a few hours PTA

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History of the Present Illness

• 4 Hours PTA– Hematochezia 4 episodes, 1 cup each,

associated with loss of consciousness– Consulted at a local hospital

• Hydration• Vitamin K• Tranexamic Acid 500mg IV

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Past Medical History

• (+) BPH– Proscar

• (+) DM Type II– Oral hypoglycemic agents

• Colonoscopy (2006)– Lower Gastro-intestinal bleeding

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Family History and Social History

• Family history unremarkable

• Smoker 30 pack years, quit in 2005

• Occasional alcoholic beverage drinker

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Course in the Wards

• Day of admission– Stable vital signs– CBC, PT/PTT were performed– PNSS 8hr, Tranexamic acid 500mg IV q8h,

Omeprazole 40mg IV OD– 3 units FWB transfusion fast drip– UGIE and colonoscopy

• erosive gastritis and multiple diverticulosis

– Tranexamic acid and Omeprazole was discontinued and diet was shifted to mechanically soft DM diet

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Course in the Wards

• 1st Hospital Day– Stable vital signs, tolerating diet, no hematochezia or abdominal

pain

• 2nd Hospital Day– Hypotension with episodes of hematochezia 1 cup each, NPO– BP: 70/40; HR: 110’s– CBC taken, Hgb 84– 4 units FWB, 2 units pRBC, 6 units FFP were transfused– Resumed Omeprazole 40mg IV OD and Tranexamic acid 500mg

IV q8– Persistently hypotensive and with hematochezia– Voluven was started, IVF rate increased to 200cc/hr, L

arm/166cc/hr R arm and Dopamine drip at 16ugtts/min

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Course in the Wards– Referred to surgery service

• Suggested to do arteriography and embolization– Arteriography unremarkable

– Patient persistently hypotensive on inotropes

• 3rd to 5th Hospital Day– Hypotensive, HR 100’s, afebrile, persistent episodes of

melena– Coughing

• CXR: elevated right hemidiaphragm due to poor ventilator effort

– Diet resumed, daily CBC taken– 3 units pRBC transfused– Persistently hypotensive, aggressive fluid resuscitation

done

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Laboratory ResultsParameter 1.3.09 1.5.09 1.6.09 1.7.09

Na 135

K 4.7

Cl -

BUN - 6.7

Creatinine 144 105 103

Total Protein Albumin Globulin

-

Hgb 122; 119 84 80 72

Hct 34; 32 24 23 20

WBC 23.9; 21.4 12.7 8.9

Neutrophils 90; 93 79 76

Lymphocytes 10; 7 13 23

Eosinophils - 8 1

Platelet

RBC

Morph

Normal

Normo

Normo

215

Hypo

Normo

190

Hypo

Normo

Imaging Results

• CXR– Clear lung fields, true cardiac size can not be

ascertained

• Mesenteric Angiogram– Superior Mesenteric Angiogram

• Good visualization of the pancreaticoduodenal, jejunal, ileal, and right colic arteries

• Selective angiograms of the middle colic and ileo-colic arteries

• No contrast material extravasation or collection• No vascular malformations, fistulae or abnormal vascularity

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Imaging Results

– Inferior Mesenteric Angiogram• Good visualization of the left and middle colic

arteries down to the hemorrhoidal arteries• No contrast media extravasation or collection• No vascular malformations, fistulae or abnormal

vascularity

– Celiac Artery Angiogram• No abnormal findings

– Impression: Negative Superior mesenteric, Inferior mesenteric and celiac angiograms

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Imaging Results• Upper GI Endoscopy Report

– Superficial whitish ulcer at the cardia, multiple biopsies done– Patient tolerated the procedure well– Impression:

• Superficial Ulcer Cardia• Erosive Gastritis, Antrum and Body • H. pylori Rapid Urease Test (+)

• Colonoscopy Report– Multiple diverticular openings in the cecum, ascending colon and

sigmoid colon– Blackish materials in the terminal ileum and the colon– Impression:

• Colonic Diverticulosis• Internal Hemorrhoids grade 1

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Clinical Impression

• DIVERTICULOSIS– acquired small pouches or sacs (diverticula) in the colon formed

by the herniation of mucosal and sub-mucosal linings through the muscular layers of the intestine

– related to alterations in bowel wall anatomy and intraluminal pressure

– usually associated with hypertrophy and brittleness of the affected colonic musculature(mychosis). The condition is thought to be caused by chronic segmental contractions of the circular muscle of the colon, which in turn causes increased intraluminal pressure, especially in the sigmoid colon, muscular hypertrophy, and herniations of mucosa through the weak areas in the colonic wall.

– It is generally assumed that the low-residue diet is a major causative factor. Advancing age is certainly another associated risk factor.

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Clinical Impression

• The diverticulum protrudes through the colonic musculature often in intimate contact with the nutritional artery artery undergoes pathologic changes characterized by eccentric muscular thickening and intimal thinning.

• Occasionally this affected artery will bleed into the diverticulum and then into the colonic lumen, the arterial bleeding can be massive in volume and yet difficult to localize.

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Clinical Impression

• The law of Laplace states that intraluminal pressure varies inversely with the radius of a cylinder and directly with the cylinder wall thickness. The narrowest portion of the colon is the sigmoid. Herniation of mucosa can then occur in areas of relative muscle weakness.

• Other age related factors contributing to increase intraluminal pressure include lower stool weights which is often related to low-fiber diet and age, increased gastrointestinal transit time which increases water absorption, and constipation which is aggravated by a sedentary lifestyle and polypharmacy.

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Differential Diagnosis

• Internal Hemorrhoids– mainly affects three complexes in the anal canal: the

left lateral, the right anterior and the right posterior – Constant engorgement and straining results in the

prolapse of this tissue into the anal canal – Classified according to the progression of the

disease:• Stage I: Enlargement and bleeding• Stage 2: Protrusion with spontaneous reduction• Stage III: Protrusion requiring manual reduction• Stage IV: Irreducible protrusion

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Differential Diagnosis

• The patient was diagnosed with stage I internal hemorrhoids.

• Typical signs include bleeding with a less common associated pain.

• The bleeding in hemorrhoidal disease is described as bright red blood seen either in the toilet or upon wiping.

• The bleeding in the patient is described as several episodes of hematochezia that prompted fluid resuscitation.

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Differential Diagnosis

• Angiodysplasia of the colon– enlargement of the blood vessels in the colon that

lead to its eventual fragility and result in occasional bleeding

– commonly seen among the aged population where degeneration of the blood vessels is more likely

– arteriovenous fistula formation puts the patient at a high risk for bleeding with bright red blood coming from the rectal area

– can be ruled out in the case by performing the mesenteric and celiac angiograms

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Differential Diagnosis

• Colon Cancer– polyps of the colorectal mucosa are extraordinarily

common in the older adult population and may cause up to 10% of acute lower gastrointestinal bleeding

– Timeline for progression from early premalignant lesion to malignant cancer ranges from 10-20 years and the incidence peaks at about age 65 years

– Advanced colon cancer often presents with symptoms, but early colon cancer and premalignant adenomatous polyps commonly are asymptomatic

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Differential Diagnosis

– Cancers arising in the cecum and ascending colon may become quite large without resulting in any obstructive symptoms or noticeable alterations in bowel habits.

– Right-sided lesions are more likely to bleed and cause diarrhea, while left-sided tumors are usually detected later and could present with bowel obstruction.

– Tumors of the ascending colon often present with symptoms such as fatigue, palpitations, and even angina pectoris and are found to have a hypochromic, microcytic anemia indicative of iron deficiency. Since the cancer may bleed intermittently, a random fecal occult blood test may be negative

– Cancers arising in the rectosigmoid are often associated with hematochezia, tenesmus, and narrowing of the caliber of stool.

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Differential Diagnosis

• Gastritis– There are four radiologic signs of acute gastritis that

are consistent regardless of the etiology. These signs include:

• Thick folds size greater than 5 mm in caliber • Inflammatory nodules may represent erosions that have

epithelialized (healed) but still have the associated edema • Coarse area gastrica may reflect inflammatory swelling • Erosions may be linear or serpiginous; may be

accompanied by edema and may be seen on or near the greater curvature of the stomach

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Diagnostic and Therapeutic Plan

• Colonoscopy, Barium Enema, and CT scan of the Abdomen– Colonoscopy is an outpatient procedure that aids in examining the

inside of the large intestine (colon and rectum)– evaluates gastrointestinal symptoms, such as rectal and intestinal

bleeding, abdominal pain, or changes in bowel habits and even in patients suspected for colorectal polyps or cancer.

– screening colonoscopy is recommended for anyone 50 years of age and older

– in case that colonoscopy is not indicated because of severe diverticulosis or the question of an obstruction or blockage, then a barium enema is another test which surgeons can use to look inside the colon and help them to decide on surgery

– Sometimes, a CT scan of the abdomen may be a useful tool to decide if a colon surgery is needed and increasingly being used to assess and treat complications such as abscess or fistula, and also to provide alternative diagnoses if diverticulosis is not confirmed.

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Diagnostic and Therapeutic Plan

• Laboratory studies: • a. measurement of complete blood count – note that an

initial hemoglobin/hematocrit value may not reflect the degree of blood loss due to volume contraction, and may fall significantly after hydration.

• b. serum electrolytes, blood urea nitrogen, and creatinine – a rise of the serum blood urea nitrogen without an associated rise in serum creatinine happens in upper gastrointestinal bleeding; This appears to be due to absorption of proteins from blood in the gastrointestinal tract, and from dehydration. However, an absence of a rise in blood urea nitrogen will not rule out an upper gastrointestinal source.

Diagnostic and Therapeutic Plan

– Apart from the laboratory test ordered for the patient, the following should also be included

• CBC count to assess for anemia, as acute gastritis can cause gastrointestinal bleeding

• Liver and kidney function tests• Gallbladder and pancreatic function tests• Stool for blood

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Diagnostic and Therapeutic Plan

• Medical Care (GOALS)– Administer medical therapy as needed,

depending on the cause and the pathological findings.

– Administer fluids and electrolytes as required, particularly if the patient is vomiting.

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Diagnostic and Therapeutic Plan

• Management– Fluid resuscitation– Acid suppression – Inhibition of fibrinolysis – Arteriographic techniques provide hemostasis

including injection of intraarterial vasopressin, or superselective embolization with materials such as gelatins or oxidized cellulose.

– Surgery

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The End