1. Jessica Cintolo Scott Q. Nguyen, M.D. Celia Divino, M.D.
Rectal Bleeding
Jessica Cintolo
Scott Q. Nguyen, M.D.
Celia Divino, M.D.
Mount Sinai School of Medicine
Department of Surgery

2. Ms. C
Ms. C is a 33-year-old female who presents to her primary care physician complaining of bloody bowel movements for the past 4 weeks.

3. What other points of the history do you want to know?

4. History, Ms. C Consider the following:
Characterization of Symptoms
Temporal sequence
Alleviating / Exacerbating factors:
Associated Signs & Symptoms
Pertinent PMH
ROS
MEDS
Relevant Family Hx.
Relevant Social Hx.

5. History, Ms. C
Characterization of Symptoms and Temporal Sequence of Events
Patient noticed bright red blood in her stool beginning 4 weeks ago, sometimes mixed with mucous. Her bowel movements have been loose but formed.
She has approximately 3 bowel movements daily and often feels an urgent need to defecate.
She has also noticed intermittent crampy abdominal pain and a decrease in appetite over the past month.

6. History, Ms. C Alleviating/Precipitating Factors Associated Symptoms
Abdominal pain often worsens with eating
Nothing alleviates symptoms
Associated Symptoms
No Nausea or Vomiting
Decreased Appetite
Weight loss of about 10 lbs over past month

7. Has this happened before?
History, Ms. C
Has this happened before?
She has experienced abdominal pain and bloody diarrhea twice in the past year but never lasting more than 2-3 days
Sick Contacts and Travel History
No known sick contacts
No recent travel out of the country

8. Additional History, Ms. C
PMH
None
PSH
Appendectomy at age 9
Meds:

9. Additional History, Ms. C
Family History
Several family members have had “intestinal problems”
Social History
Smoked ½ pack per day for 10 years until 2 years ago, social ETOH consumption, no other drug use
Sexually active in monogamous relationship

10. What is you Differential Diagnosis?

11. Differential Diagnosis Based on History and Presentation
Inflammatory Bowel Disease
Crohn’s Disease
Ulcerative Colitis
Infectious Colitis
Parasites: Strongyloidiasis, Amebiasis
Rectal or Colon Cancer or Lymphoma
Diverticulitis
Radiation Enteritis
Gastroenteritis

12. What specifically would you look for?
Physical Examination
What specifically would you look for?

13. Physical Examination, Ms. C
Vital Signs: T = 37.3, P = 86, BP = 110/76, RR = 14
Appearance: thin, pale, but in no acute distress
HEENT: Sclera anicteric, mucous membranes pink and moist
Heart: RRR
Lungs: mild rales at bases
Abdomen: normoactive BS, non-distended, mildly tender throughout, no guarding or rebound tenderness
Rectal: stool in vault mixed with bright red blood, no masses, no external anal lesions

14. Differential Diagnosis Would you like to update your differential?

15. Laboratory
What would you obtain?

16. Lab Results MCV = 82% LFTs WNL PT/PTT WNL Stool O&P negative
C. difficile toxin negative
10.9
6.7
138
108 12
225
32.3 98
3.7
24.0
0.7

17. Laboratory Results-Discussion
Normal WBC – infection less likely
Mild Anemia – likely from GI bleeding with chronic blood loss given low MCV
Electrolytes - Normal
C. difficle toxin negative - sensitivity is 80-99% based on assay with specificity of 99% making infection with C. difficile highly unlikely

18. What are the Next Steps in Diagnosis and Management?

19. Further Diagnosis and Management
Interventions?
Imaging?
Endoscopy?

20. Abdominal X-Ray

21. X-ray interpretation Normal Abdominal Film No colonic dilatation
No signs of small bowel obstruction or ileus

22. What would you expect to see?
Colonoscopy
What would you expect to see?

23. Colonoscopy: Findings & Discussion
Continuous inflammation of colonic mucous involving rectum and extending to the splenic flexure and into the early transverse colon
Mucosa is erythematous, edematous, and friable
Pseudopolyps – inflammatory, non-neoplastic mucosal projection
Mucosal Biopsy demonstrates distortion of architecture with crypt branching, crypt abscess containing inflammatory cells, ulceration; no granulomas

24. Final Diagnosis
Ulcerative Colitis

25. What next?

26. Medical Management for Mild-to-Moderate Ulcerative Colitis
5-ASA agents
oral and rectal preparations
Oral Corticosteroids
6-MP/Azathioprine

27. Medical Management, Ms. C
Ms. C is started on Sulfasalazine 1g TID and also given a course of steroids
Her symptoms improve dramatically over the next few days
She maintains Sulfasalazine therapy for disease control despite minimal symptoms

28. Ms. C returns
Ms. C now presents to the emergency department 3 weeks after completing the steroid taper. She began having crampy abdominal pain and bloody diarrhea 2 weeks ago increasing in severity over the past 5 days.

29. History, Ms. C
Characterization of Symptoms and Temporal Sequence of Events
Abdominal pain began gradually 2 weeks ago, was intermittent and crampy, but now worsening in severity and constant
Diarrhea also began 2 weeks ago. It was watery and mixed with bright red blood. Over the past 5 days patient has noted more blood in the toilet bowl.
She has been having >10 Bowel movements daily
Today diarrhea is less than it has been the day before

30. History, Ms. C Alleviating/Precipitating Factors Associated Symptoms
She attempted to take over-the-counter anti-diarrheal agents without relief
Patient feels worse with eating; she has avoided oral intake for the past week
Associated Symptoms
Subjective fevers and chills
Dizziness, particularly on standing
Nausea, but no vomiting
No joint pain, no visual changes or eye pain

31. Physical Examination, Ms. C
V.S. T=38.7°C, BP=104/60 (seated), 90/50 (standing), HR=102 (seated), 116 (standing)
General: thin, uncomfortable
HEENT: sclera anicteric, mucous membranes dry, no oral lesions
Cardiovascular: tachycardic, normal S1, S2, grade II/VI systolic flow murmur

32. Physical Exam Lungs: Clear to Auscultation Bilaterally
Abdominal Exam: Hypoactive BS, mildly distended, soft, diffusely tender but without rebound or guarding
Rectal: no external anal lesions, heme + stools
Extremities: trace pedal edema

33. Differential Diagnosis Would you like to update your differential?

34. Laboratory
What would you obtain?

35. Lab Results PMN’s =80% MCV = 80.1 LFTs WNL PT/PTT normal
VBG: 7.35/35/40
AG= 10
Lactate: 1.1
Cultures and Stool Studies pending
8.9
140
111 37
11.2
300 28
2.9 18
1.3

36. Laboratory Results-Discussion
Leukocytosis – consistent with inflammation, could indicate infection
Anemia – indicative of blood loss, likely acute on chronic blood loss given low MCV
Mild Non-anion gap Metabolic Acidosis with appropriate respiratory compensation – seen in the context of diarrhea
Hypokalemia – GI losses and volume depletion

37. Interventions at this point?

38. Consider the following Immediate Interventions
Admit to Hospital
NPO
Fluid Resuscitation with Isotonic Crystalloid
(NS, LR, or Plasmalyte)
Correct Electrolyte Abnormalities
Stop any narcotic, antidiarrheal, or anticholinergic agents
Begin IV Corticosteroids

39. Do you want any further studies?

40. Abdominal X-Ray

41. Abdominal X-ray Discussion
Dilated Colon
Toxic Megacolon
Dilation of Transverse or Ascending Colon >6cm
No small bowel pathology

42. Colonoscopy

43. Colonoscopy findings Fulminant Colitis Friable, Ulcerated Mucosa
Mucosal Edema and Erythema
Hemorrhagic

44. Colonoscopy - Discussion
Generally avoided during fulminant presentations of colitis
May be used cautiously to determine presence of ischemic or pseudomembranous colitis
Minimize insufflation used
Should not be performed when there is colonic dilation and is contraindicated for cases of toxic megacolon

45. Abdominal CT (not necessary)

46. Abdominal CT - Interpretation
Severe Colitis
Diffuse Colonic Wall Thickening with Submucosal Edema
Pericolic Stranding
Ascites

47. Medical Management of Severe Ulcerative Colitis
Cyclosporine
Calcineurin inhibitor
Administer 2-4mg/kg/day as continuous IV infusion if patient not responding to IV corticosteroids
Infliximab
Monoclonal antibody to TNFα
Administered as IV infusion

48. Hospital Course Symptoms do not improve on steroids and cyclosporine
She continues to experience bloody diarrhea and worsening abdominal pain.

49. Final Diagnosis
Ulcerative Colitis complicated by Fulminant Colitis with Toxic Megacolon

50. What next?

51. Management Continue Supportive Therapy Medical Management
Broad spectrum antibiotics – will treat any infectious component and also offer coverage should perforation occur
Continue IV corticosteroids
Bowel Decompression may be considered when colon is dilated using Rectal Tube
Prepare for Surgery

52. Indications for Surgery
Perforation
Uncontrolled Bleeding
Progressive Dilation
Worsening Symptoms
Failure to Improve with Medical Management within 24 hours
* Delay in surgical intervention leading to emergent surgery is associated with increased morbidity and mortality.

53. Surgical Options
Subtotal Colectomy and End Ileostomy (leaving rectal stump)
Avoid the prolonged procedure of total proctocolectomy and extensive pelvic dissection
Each may be followed by elective restoration of bowel continuity and pouch construction at a later date
Total Proctocolectomy with Ileal Pouch–Anal Anastomosis (IPAA)
rarely performed during fulminant presentations due to high incidence of morbidity
increased rate of reoperation and anastomotic complications

54. Subtotal Colectomy Remove diseased colon Create ileostomy
Allow toxic state to resolve
Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) at a later date

55. Discussion
Serious Complications of fulminant presentations of Ulcerative Colitis include:
Massive Hemorrhage
Perforation
Toxic Megacolon
Toxic Megacolon is defined as colonic distension >6cm in the presence of an active inflammatory process.
Though most commonly associated with IBD, toxic megacolon may also complicate infectious colitis including Pseudomembranous colitis.

56. Discussion
Diagnosis
There may be a history of Ulcerative Colitis, but approximately 10% of patients will present initially with fulminant colitis.
History usually includes cramping abdominal pain, increased bowel movements, and stool mixed with blood and mucous.
There is often leukocytosis, anemia, and electrolyte disturbances.

57. Discussion
Diagnosis
If toxic megacolon occurs, dilated colon will be visible on abdominal x-ray and CT. CT is a good non-invasive modality for identifying subclinical complications of fulminant colitis such as perforations and abscesses.
Colonoscopy should be used with care when disease is active and is contraindicated if colon is dilated or patient has fulminant colitis

58. Discussion Management
Non-surgical management includes aggressive fluid resuscitation, correction of electrolyte abnormalities, administration of broad spectrum antibiotics, and in the case of IBD (ulcerative colitis or Crohn’s disease), administration of corticosteroids
Additional medical management may include immune modulator therapy with cyclosporine or infliximab
Colonic decompression for dilated colon may be employed

59. Discussion Management
Surgery is indicated when signs and symptoms fail to improve with medical management or worsen
Emergent Surgery is also warranted in the setting of perforation, hemorrhage, progressive dilation or toxic megacolon.
Surgical Management, consists of subtotal colectomy with end-ileostomy for emergency situations and must be pursued aggressively when indicated as delay leads to increased morbidity and mortality

60. QUESTIONS ??????

61. References
Baumgart DC, Sandborn WJ. “Inflammatory Bowel Disease: clinical aspects and evolving therapies.” Lancet. 2007;369:
Cima, RR and Pemberton JH. “Surgical Indications and Procedures in Ulcerative Colitis.” Current Treatment Options in Gastroenterology. 2004;7:
Modigliani, R. “Medical Management of Fulminant Colitis.” Inflammatory Bowel Diseases. 2002;8(2):
Bullard KM, Rothenberger DA. “Colon, Rectum & Anus.” Schwartz's Principles of Surgery. 8th Edition.
S. Ian Gan and P.L. Beck. “A New Look at Toxic Megacolon: An Update and Review of Incidence, Etiology, Pathogenesis, and Management.” The American Journal of Gastroenterology. 2003;98(11):
Rüssmann H, Panthel K, Bader RD, Schmitt C, Schaumann R. “Evaluation of three rapid assays for detection of Clostridium difficile toxin A and toxin B in stool specimens.” Eur J Clin Microbiol Infect Dis Feb;26(2):115-9
Strong, Scott. “Fulminant Colitis: the case for operative management.” Inflammatory Bowel Diseases. 2002;8(2):

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