CASEPRESENTATION

by

Dr Aijaz SoomroResident FCPSMedical Unit II

Civil Hospital LarkanaTuesday Feb 28, 2017

A 28 years old male Mr. Mujahid resident of Bakrani, Larkana admitted in medical unit-II on 13th January 2017 via OPD with chief complaint:

Loose Bloody Stools for 2 months

BIODATA

According to the patient he was in his usual

state of health 2 months back then he gradually developed loose motions on and off that are half cup in quantity, 4-5 episodes per day, watery in consistency containing blood and mucous, blood is fresh red in color mixed with stool.

Loose motions are associated with lower abdominal pain and feeling of incomplete evacuation but not associated with fever or weight loss.

History of Presenting Complaint

Loose motions are not associated with

alternate constipation, cough, night sweats, vomiting and or joint pain.

.

Past Medical History: Not significant.

Past Surgical History: Not significant.

PAST HISTORY

Father and mother are alive and healthy. Patient has 3 sisters and 1 brother, all are

healthy. No history of any chronic illness like diabetes,

hypertension, tuberculosis.

FAMILY HISTORY

ORS Tab. Flagyl 400mg Tab. Novidat 500mg Cap. Risek 20 mg Tab. Panadol

DRUG HISTORY

No previous history of transfusion.

TRANSFUSION HISTORY

Unmarried. No history of smoking or any

addiction. Sleep pattern is normal. Bladder habits and appetite are

normal.

PERSONAL HISTORY

Lives in mud brick house. Source of water is hand pump. Hygienic conditions are not adequate.

SOCIOECONOMIC HISTORY

28 years old Mr. Mujahid presented with

complain of bloody loose stools for 2 months on and off that are small in quantity, 4-5 episodes per day, containing fresh blood and mucous mixed with stool associated with lower abdominal pain and feeling of incomplete evacuation after defecation.

CASE SUMMARY

Ulcerative Colitis Crohn’s Colitis Amebiasis Pseudomembranous Colitis HIV colitis Chronic Shigellosis

DIFFERENTIAL DIAGNOSES?

EXAMINATION

.

Young aged male patient with average height

& built lying comfortably on bed, well oriented with time, place and person.

GENERAL SURVEY & VITALS

BP: 100/7o mmHgPulse: 104 beats/minR/R: 16 breaths/minTemp: 98F

SUBVITALS

Anemia: Positive Jaundice: Negative Clubbing: Negative Cyanosis: Negative Koilony: Negative Leucony: Negative

Edema: Negative Dehyd: Positive JVP: Not raised Thyroid: Not enlarged Lymph Nodes: Not

palpable

Soft , tender at lower abdomen.Neither distended nor sunken.No any prominent veins, scar or pulsations are

visible.There is no any visceromegaly.Liver span 10cmShifting dullness or fluid thrill are negative.Bowel sounds were increased in frequency

and intensity.

ABDOMINAL EXAMINATION

Chest CVS CNS

examinations

OTHER SYSTEMS

Unremarkable

28 years old Mr. Mujjahid presented with complain

of bloody loose stools for 2 months on & off that were small in quantity, 4-5 episodes per day, containing blood & mucous mixed with stool. Loose motions were associated with lower abdominal pain & sense of incomplete evacuation.

On examination: BP: 100/70 mmHg, Pulse: 104 bpm. Temperature is normal. Anemia, and dehydration are present. Abdomen is tender at lower abdominal region.

CASE SUMMARY

INVESTIGATIONS

.

CBC

COMPLETE BLOOD COUNT

Hgb: 10.3 Gram/dl MCV: 78.5 fL [76-96] HCT: 36.8% [30-40] MCH: 27.7 pg [27-32] MCHC: 35.3 Gram/dL[30-

35] Platelets: 665k/µL [150-

450k]

WBC: 18,400/µL (4000 to 11000)

Neutrophils: 81% (50-70%)

Lymphocytes: 15% (20-50%)

Monocytes: 3%(1-4%)

Eosinophils: 1% (0-1%)

80 mm/hour (Normal 0-22 mm/hr)

ESR

UCE

Urea: 25 mg/dL (15 to 50 mg/dL) Creatinine: 1.0 mg/dL (0.6 to 1.2mg/dL) Sodium: 142 mmol/L (135-145mmol/L) Potassium: 4.3 mmol/L (3.5-5.0mmol/L) Chloride: 101 mmol/L (96 and 106mmol/L)

UCE

RBS

RBS: 119 mg/dL (80-180mg/dL)

RBS

NEGATIVE

VIRAL MARKERS

NEGATIVE

HIV

Serum Albumin 2.5 G/dl (3.0-5.0G/dL)

SERUM PROTEIN

NORMAL

CHEST X-RAY

NORMAL

U/S ABDOMEN

NORMAL

X-RAY ABDOMEN

FAECES EXAMINATION

Stool Microscopy

Color: Brown Quantity: 4 Grams Consistency: Watery Mucous: Positive Blood: Positive Worms: Nil

Red cells: 6-8 Pus cells: 5-6 Protozoa Vegetative – Nil Cystic – Nil Helminth ova - Nil

COLONOSCOPY

Scope advanced up to Terminal Ileum

Findings: Multiple polyps with high vascularity noted from terminal ileum, descending colon to rectum. A mass noted some 15-20cm from anal verge.Multiple biopsies taken from the mass and Rectum for Histopathology. Overall findings are suggestive of Polyposis Coli or CA Rectum

COLONOSCOPY

Colonic Biopsy

GROSS DESCRIPTION:

The specimen is received in formalin coded as "Mass and Rectum". It consists of multiple tan brown tissue fragments measuring 1.2 * 0.3 cm. Entirely submitted in single cassette.

MICROSCOPIC DESCRIPTION:

Sections reveal fragments of tissue which exhibit marked inflammation along with cryptitis and crypt abscesses. Granulation tissue with vessels is noted. However, there is no evidence of malignancy in the examined material. Cytokeratin AE1/AE3 highlights a normal architecture.

BIOPSY

Marked inflammation along with cryptitis and crypt abscesses. Granulation tissue with vessels and no evidence of malignancy suggests Ulcerative Colitis.

Conclusion

ULCERATIVE COLITIS

DIAGNOSIS

What could be the reason endoscopy found polyps in colon? What are categories of severity in ulcerative colitis and where in does this patient fall? What are the parameter to assess the severity of ulcerative colitis? How did you manage this case? What is the appropriate dose of corticosteroids in a patient with ulcerative colitis? What if mesalamine and corticosteroids do not work in this patient? Which Enzyme abnormality interferes metabolism of Thiopurines? How will you treat ulcerative colitis in pregnancy? How and when should this patient be reassessed through endoscopy for protection from

malignancy? ESR is high and patient is afebrile. What could be the reason? What is the role of Infliximab in ulcerative colitis? What are the extraintestinal manifestations of ulcerative colitis? What are extraintestinal manifestations specific to liver? What are the complications of severe disease? How will you diagnose Toxic Megacolon and what is the management? How will you monitor disease activity? Which antibodies can be detected in patient with ulcerative colitis? Which corticosteroid is the most appropriate in patient with ulcerative colitis? What are the indications of Colectomy?

Questions from Audience at the end of Presentation