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 BleedingJessica CintoloScott Q. Nguyen, M.D.Celia Divino, M.D.Mount Sinai School of MedicineDepartment of Surgery
2 Ms. CMs. 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 SymptomsTemporal sequenceAlleviating / Exacerbating factors:Associated Signs & SymptomsPertinent PMHROSMEDSRelevant Family Hx.Relevant Social Hx.
5 History, Ms. CCharacterization of Symptoms and Temporal Sequence of EventsPatient 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 eatingNothing alleviates symptomsAssociated SymptomsNo Nausea or VomitingDecreased AppetiteWeight loss of about 10 lbs over past month
7 Has this happened before? History, Ms. CHas this happened before?She has experienced abdominal pain and bloody diarrhea twice in the past year but never lasting more than 2-3 daysSick Contacts and Travel HistoryNo known sick contactsNo recent travel out of the country
8 Additional History, Ms. C PMHNonePSHAppendectomy at age 9Meds:
9 Additional History, Ms. C Family HistorySeveral family members have had “intestinal problems”Social HistorySmoked ½ pack per day for 10 years until 2 years ago, social ETOH consumption, no other drug useSexually active in monogamous relationship
11 Differential Diagnosis Based on History and Presentation Inflammatory Bowel DiseaseCrohn’s DiseaseUlcerative ColitisInfectious ColitisParasites: Strongyloidiasis, AmebiasisRectal or Colon Cancer or LymphomaDiverticulitisRadiation EnteritisGastroenteritis
12 What specifically would you look for? Physical ExaminationWhat specifically would you look for?
13 Physical Examination, Ms. C Vital Signs: T = 37.3, P = 86, BP = 110/76, RR = 14Appearance: thin, pale, but in no acute distressHEENT: Sclera anicteric, mucous membranes pink and moistHeart: RRRLungs: mild rales at basesAbdomen: normoactive BS, non-distended, mildly tender throughout, no guarding or rebound tendernessRectal: stool in vault mixed with bright red blood, no masses, no external anal lesions
14 Differential Diagnosis Would you like to update your differential?
17 Laboratory Results-Discussion Normal WBC – infection less likelyMild Anemia – likely from GI bleeding with chronic blood loss given low MCVElectrolytes - NormalC. 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?
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? ColonoscopyWhat 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 colonMucosa is erythematous, edematous, and friablePseudopolyps – inflammatory, non-neoplastic mucosal projectionMucosal Biopsy demonstrates distortion of architecture with crypt branching, crypt abscess containing inflammatory cells, ulceration; no granulomas
26 Medical Management for Mild-to-Moderate Ulcerative Colitis 5-ASA agentsoral and rectal preparationsOral Corticosteroids6-MP/Azathioprine
27 Medical Management, Ms. C Ms. C is started on Sulfasalazine 1g TID and also given a course of steroidsHer symptoms improve dramatically over the next few daysShe maintains Sulfasalazine therapy for disease control despite minimal symptoms
28 Ms. C returnsMs. 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. CCharacterization of Symptoms and Temporal Sequence of EventsAbdominal pain began gradually 2 weeks ago, was intermittent and crampy, but now worsening in severity and constantDiarrhea 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 dailyToday 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 reliefPatient feels worse with eating; she has avoided oral intake for the past weekAssociated SymptomsSubjective fevers and chillsDizziness, particularly on standingNausea, but no vomitingNo joint pain, no visual changes or eye pain
35 Lab Results PMN’s =80% MCV = 80.1 LFTs WNL PT/PTT normal VBG: 7.35/35/40AG= 10Lactate: 1.1Cultures and Stool Studies pending8.91401113711.2300282.9181.3
36 Laboratory Results-Discussion Leukocytosis – consistent with inflammation, could indicate infectionAnemia – indicative of blood loss, likely acute on chronic blood loss given low MCVMild Non-anion gap Metabolic Acidosis with appropriate respiratory compensation – seen in the context of diarrheaHypokalemia – GI losses and volume depletion
38 Consider the following Immediate Interventions Admit to HospitalNPOFluid Resuscitation with Isotonic Crystalloid(NS, LR, or Plasmalyte)Correct Electrolyte AbnormalitiesStop any narcotic, antidiarrheal, or anticholinergic agentsBegin IV Corticosteroids
44 Colonoscopy - Discussion Generally avoided during fulminant presentations of colitisMay be used cautiously to determine presence of ischemic or pseudomembranous colitisMinimize insufflation usedShould not be performed when there is colonic dilation and is contraindicated for cases of toxic megacolon
46 Abdominal CT - Interpretation Severe ColitisDiffuse Colonic Wall Thickening with Submucosal EdemaPericolic StrandingAscites
47 Medical Management of Severe Ulcerative Colitis CyclosporineCalcineurin inhibitorAdminister 2-4mg/kg/day as continuous IV infusion if patient not responding to IV corticosteroidsInfliximabMonoclonal antibody to TNFαAdministered 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 DiagnosisUlcerative Colitis complicated by Fulminant Colitis with Toxic Megacolon
51 Management Continue Supportive Therapy Medical Management Broad spectrum antibiotics – will treat any infectious component and also offer coverage should perforation occurContinue IV corticosteroidsBowel Decompression may be considered when colon is dilated using Rectal TubePrepare for Surgery
52 Indications for Surgery PerforationUncontrolled BleedingProgressive DilationWorsening SymptomsFailure 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 OptionsSubtotal Colectomy and End Ileostomy (leaving rectal stump)Avoid the prolonged procedure of total proctocolectomy and extensive pelvic dissectionEach may be followed by elective restoration of bowel continuity and pouch construction at a later dateTotal Proctocolectomy with Ileal Pouch–Anal Anastomosis (IPAA)rarely performed during fulminant presentations due to high incidence of morbidityincreased rate of reoperation and anastomotic complications
54 Subtotal Colectomy Remove diseased colon Create ileostomy Allow toxic state to resolveRestorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) at a later date
55 DiscussionSerious Complications of fulminant presentations of Ulcerative Colitis include:Massive HemorrhagePerforationToxic MegacolonToxic 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 DiscussionDiagnosisThere 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 DiscussionDiagnosisIf 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 corticosteroidsAdditional medical management may include immune modulator therapy with cyclosporine or infliximabColonic decompression for dilated colon may be employed
59 Discussion Management Surgery is indicated when signs and symptoms fail to improve with medical management or worsenEmergent 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
61 ReferencesBaumgart 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):115-9Strong, Scott. “Fulminant Colitis: the case for operative management.” Inflammatory Bowel Diseases. 2002;8(2):
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