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Jessica Cintolo Scott Q. Nguyen, M.D. Celia Divino, M.D.

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Presentation on theme: "Jessica Cintolo Scott Q. Nguyen, M.D. Celia Divino, M.D."— Presentation transcript:

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):

62 Acknowledgment The preceding educational materials were made available through the ASSOCIATION FOR SURGICAL EDUCATION In order to improve our educational materials we welcome your comments/ suggestions at:

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