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Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine. http://clinicalcorrelations.org. Medical Grand Rounds Clinical Vignette October 8, 2008. Sabina Berezovskaya, M.D. Chief Complaint.

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Clinical Correlations The NYU Internal Medicine BlogA Daily Dose of Medicine

http://clinicalcorrelations.org


Medical Grand RoundsClinical VignetteOctober 8, 2008

Sabina Berezovskaya, M.D.


Chief Complaint

  • 49 year old male presents with early satiety for three months and one day of red blood and clots mixed with stool one week prior to presentation.


History of Present Illness

  • He was in his usual state of health until three months prior to admission when he began experiencing frequent early satiety and subjective weight loss.

  • One week prior to presentation patient noted bright red blood per rectum with clots which spontaneously resolved after one day.

  • One day prior to admission, he had routine labs drawn at his cardiology clinic appointment.

  • He was recalled for admission when his hemoglobin returned significantly decreased from his baseline.


Further history

  • Past Medical History:

    • GERD

    • Diabetes Mellitus Type II

    • Hypercholesterolemia

    • Hypertension

    • Coronary artery disease (CAD) with prior STEMI (10/07) requiring percutaneousstenting of the RCA

  • Past Surgical History: Denies

  • Social History:

    • Prior history of alcohol abuse (20 beers per day). Last use 2 years ago

    • No tobacco or illicit drug use

  • Family History: Non-contributory

  • Medications:

    • Aspirin 81 mg daily

    • Clopidogrel 75mg daily

    • Metoprolol 50 mg twice a day

    • Lisinopril 20 mg daily

    • Simvastatin 40 mg daily

    • Metformin 1g twice a day

    • Pioglitazone 30 mg daily

    • Esomeprazole 40 mg daily

  • Allergies: no known drug allergies


Physical Exam

  • General : Well nourished and well developed male; in no acute distress

  • Vital signs: T- 98º F BP: 99/75 HR: 62 RR: 18 O2 sat: 100% RA

    • Orthostatics were negative

  • Abdomen: mildly tender at the right lower quadrant

  • Rectal: no masses or tenderness; black guaiac + stool

    The physical exam was otherwise entirely normal.


Laboratory Findings

  • WBC: 7.7, normal differential

  • Hgb: 7.9 g/dl, MCV 65.6, RDW: 15.8

    • Prior baseline hgb 13-14g/dl

  • Platelets: 384

  • Iron: 16 mcg/dL (nl: 42-146)

  • TIBC: 462 mcg/dL (nl: 250-450)

  • Ferritin: 4.8 ng/mL (nl: 22-322)

  • Basic metabolic panel, liver function tests, amylase, lipase & coagulation profile were all within normal limits


Imaging

  • Chest x-ray: no cardiopulmonary disease

  • EKG: normal sinus rhythm with q waves in II,III, aVF; unchanged from prior baseline.


Working diagnosis

Lower Gastrointestinal Bleed


Colonoscopy

  • A single sessile polyp measure 6mm in size was found in the hepatic flexure.

  • The polyp was removed with a hot snare

  • There was a friable non-obstructing circumferential tumor in the ascending colon immediately distal to the IC valve


Colonoscopy


Pathologic Diagnosis

Poorly Differentiated Invasive Carcinoma

+ for Cytokeratin 20 and Neuron Specific Enolase (NSE)

- for Cytokeratin 7, Synaptophysin or Chromographin


Clinical Staging Evaluation

  • Abdomen & Pelvis CT:

    Ascending colon tumor with multiple enlarged adjacent mesenteric lymph nodes

  • Chest CT:

    No evidence for intrathoracic metastatic disease

  • CEA <0.5 (nl <=5)


Abdominal / Pelvic CT Scan


Hospital Course

  • Patient was transfused with 1 Unit of packed red blood cells and started on Iron supplementation

  • He remained hemodynamically stable and had no recurrent episodes of bleeding

  • Patient was evaluated by surgical consult and a right hemicolectomy was scheduled


Final Diagnosis

Lower Gastrointestinal Bleed due to

Poorly Differentiated Adenocarcinoma of the ascending colon and the hepatic flexure


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