NYU Medical Grand Rounds Clinical Vignette

1. NYU Medical Grand Rounds Clinical Vignette Rennie Rhee MD, PGY-2 January 13, 2010 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

2. Chief Complaint A 51-year-old man presents with bloody diarrhea for 6 months. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

3. History of Present Illness • The patient was in his usual state of health until 6 months prior to admission, when he began to experience fever and bloody diarrhea. • He would experience 10-15 episodes of diarrhea per day with increasing amount of blood clots noted in his stool. • At that time, the patient initially presented to the emergency room and an abdominal CT demonstrated pancolitis. • The patient was given presumptive diagnosis of infectious enterocolitis and discharged home on antibiotics. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

4. History of Present Illness • Two weeks later, the patient presented in clinic reporting persistence of his diarrhea. • Colonoscopy was performed showing patchy erythematous mucosa of the colon. • Biopsy demonstrated a slight increase of lymphoplasmacytic infiltrate from terminal ileum to the sigmoid colon, but mature glands with little crypt distortion and mature globlet cells. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

5. History of Present Illness • Given the unclear etiology of his diarrhea, the patient was given a trial of loperamide, but without relief. • He was later given a trial of mesalamine for possible ulcerative colitis, and this provided marked improvement. • 5 days prior to admission, however, the patient experienced recurrence of his frequent episodes of bloody diarrhea, abdominal pain, and rectal burning. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

6. Additional History • Past Medical History • None • Past Surgical History • None • Family History • Father: Myocardial infarction at age 68 • Social History • Smoker, 40 pack-years • Denies alcohol use • Denies illicit drug use UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

7. Outpatient Medications Mesalamine 800mg three times daily Allergies: Penicillin (anaphylaxis) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

8. Physical Examination General: Well-appearing middle-aged man, in no acute distress Vitals: T 102.8F, BP 118/69, HR 91, RR 16 O2 saturation: 97% on room air Abdominal: Soft, distended, normal bowel sounds, left lower quadrant pain on light and deep palpation The remainder of the physical exam was normal. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

9. Initial Studies • CBC: • Hemoglobin 11.2 g/dL, Hematocrit 34% • The remainder was within normal limits • Basic Metabolic Panel: Within normal limits • Hepatic Panel: Within normal limits • C-reactive protein: 94 mg/L (0.215 – 3.0 mg/L) UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

10. Imaging • Abdomen and Pelvis CT: • Colonic inflammatory changes involving mid transverse colon to rectum • Interval decrease in rectosigmoid inflammation • Abdominal lymph nodes measuring up to 1.3 cm in right lower quadrant, most likely reactive • Dilated appendix UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

11. Working Diagnosis Acute Exacerbation of Ulcerative Colitis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

12. Hospital Course • The patient was started on prednisone and his mesalamine dose was increased. Mesalamine enemas were also initiated. • Ciprofloxacin and metronidazole were empirically started due to concern for acute appendicitis. • General Surgery recommended no surgical intervention. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

13. Hospital Course • During his hospitalization, the colonoscopy was repeated due to the original atypical biopsy results. • New biopsies revealed chronic active colitis with crypt distortion, cryptitis, and crypt abscesses. • The patient’s symptoms slowly improved and he was discharged in stable condition. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

14. Final Diagnosis Ulcerative Colitis UNITED STATES DEPARTMENT OF VETERANS AFFAIRS