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CASE PRESENTATION

CASE PRESENTATION. By, Dr. Syed Hunain Riaz PGR M-II JHL. PRESENTING COMPLAINTS. Black colored stools  1 month Generalized weakness 1 month. HISTORY OF PRESENTING ILLNESS.

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CASE PRESENTATION

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  1. CASE PRESENTATION By, Dr. Syed Hunain Riaz PGR M-II JHL

  2. PRESENTING COMPLAINTS • Black colored stools1 month • Generalized weakness1 month

  3. HISTORY OF PRESENTING ILLNESS • Ashraf, a 40 years old man, presented with a month’s history of black colored stools, with no h/o associated black colored vomiting • Stools were sticky, 4-5 times a day on average, and fouls smelling • No associated unconsciousness, abdominal distention, jaundice or body swellings

  4. No h/o abdominal pain • No h/o heartburn/pain before or after meals, no h/o regurgitation after meals, no h/o back pain after meals • No h/o difficulty in swallowing

  5. No h/o anorexia or weight loss appreciated by the patient • No h/o any worms in stools • Has previously had such an episode for which was re-admitted in LGH • No h/o chest pain on rest or at exertion.

  6. H/o dyspnea on exertion, no orthopnea • No h/o burning or numbness of hands or feet • There is h/o medication intake for pain for trauma to his spine for which he was admitted in LGH 6 months back • No documentation of any multivitamin intake

  7. No h/o joint pains or swellings • H/o multiple tooth extractions in the past from quacks • There is no h/o blood transfusions • No family h/o any such disease

  8. PAST HISTORY • Was admitted in LGH for trauma to his spine • Was unable to move his legs and developed urine and fecal incontinence • Underwent spine surgery. • Regained ability to move his legs • Was unable to lift his feet of the ground, and the urine and fecal incontinence persisted

  9. According to Xrays. He had a prosthetic vertebrae inserted in his spine, level of L5 • Given routine painkillers during stay in orthopedics ward, • Discharged and returned home, during his stay he did not develop any new complaints • After a month, developed black colored stools, with no associated vomiting. There was no unconsciousness or fits

  10. He was re-admitted in LGH, developed mild-moderate abdominal distention • Diagnosed at as a case of CLD at LGH • Treated and discharged

  11. The malena remained settled, the abd distention also, but after two months, he again developed malena, which lasted a month before he came to JHL • Non- diabetic, non-hypertensive, no h/o tuberculosis or asthma

  12. FAMILY HISTORY • Parents both deceased, no account on cause of death. • No h/o any such disease in siblings, no family h/o tuberculosis, asthma or diabetes

  13. PERSONAL HISTORY • Non-smoker • Non-addict

  14. SOCIOECONOMIC HISTORY • Has no source of income currently, after being unable to walk • Low socioeconomic status

  15. EXAMINATION

  16. General Physical Exam • Middle aged man, lying in bed, with a markedly pale look • Well oriented in time place and person • Urinary catheter in place and wearing a pamper

  17. Pallor: + + + • Cyanosis: - • Clubbing: - • Jaundice:- • Leuconychia: - • Koilonychia: - • Palmar Erythema: - • Dupytren’s contracture: - • Lymph nodes: No clinically significant lymph nodes palpable • Pedal edema: - • Normal papillae on tongue, no mouth ulcers, no stomatitis

  18. BP: 130/80 mm HG • Pulse: 110/min, is regular • Temp: Afebrile • R/R: 18/min

  19. GASTROINTESTINAL EXAM • Abdomen protuberant with central and inverted umblilicus • No prominent veins, or pulsations • A surgical scar in left hypochondrium about 5 inches in length • No gynaecomastia, or spider nevi

  20. Abdomen non-tender • Fluid appreciated in flanks ( on shifting dullnes ), otherwise gaseous distention • Liver lower edge 4-5 centimeters in mid clavicular line, smooth surface, non tender and regular margins, upper border percussed in right 5th ICS ( span about 15 cms ) • Spleen palpated about 5 inches below left costal margin, non tender, smooth in consistency and regular margins • Kidneys not palpable • Bowel sounds audible

  21. CARDIOVASCULAR EXAM • Shape of chest normal, no scars, no prominent veins, no pulsations • Apex beat palpated in left 5th ICS, normal in character • Ejection systolic murmur heard, loud at aortic area

  22. NERVOUS SYSTEM • Higher mental functions intact • Motor system in upper limbs revealed no finding • Motor system in lower limb: • Power:5/5 bilaterally in proximal muscles • 0/5 in muscles of dorsiflexion/plantarflexion bilaterally • Reflexes: Normal knee jerks bilaterally • Absent Ankle jerks bilaterally • Sensory system intact in all the limbs • No cerebellar signs in upper limbs, could not assess in lower limbs

  23. Respiratory Exam • Normal shape of chest • Normal chest expansion • Chest moving bilaterally equally with respiration • Normal vesicular breathing

  24. DIFFERENTIAL DIAGNOSIS FROM THE INFO SO FAR? • VARICEAL BLEED WITH UNDERLYING CLD? • NSAID INDUCED GASTRITIS/PEPTIC ULCER? • STRESS ULCERS? • GASTRIC/SMALL INTESTINAL MALIGNANCY?

  25. INVESTIGATIONS

  26. Complete Blood Examination • CBC: • Hb: 3.2 g/dl • HCT: 12.3 % • RBC: 1600/mm³ • WBC: 10,000/mm³ • DLC: N: 55 % • L: 40 % • M: 3% • E: 2% • Platelets: 202,000/mm³

  27. RBC INDICES: • MCV: 76 fl • MCH: 20 • MCHC: 26 pg • RETICS: 1.5 % • RETIC INDEX: 0.16 • LDH: 298 U/L

  28. RBC MORPHOLOGY: • Hypchromia: ++ • Macrocytosis: ++ • Poikilocytosis: ++ • Anisocytosis: ++ • Target cells: ++

  29. STOOL EXAMINATION: • + for occult blood on two occasions • No ova cysts or parasites seen • No presence of fat

  30. URINE EXAMINATION: • Normal color and pH • No red blood cells or pyuria • Normal urobilinogen content • No presence of bilirubin

  31. LFT’S: • Bilirubin: 0.6 • SGPT: 13 u/l • Alk Phos: 212 u/l • S/Albumin: 3.7 g/dl • PT: 15/13 • aPTT: 35/33 • RFT’S: • B/Urea: 21 mg/dl • S/Creatinine: 0.6 mg/dl

  32. USG ABDOMEN/PELVIS: • Liver 16 cm’s in span, slightly coarse echotexture • portal vein diameter 13 mm • No focal lesion, no varices at porta-hepatis, or splenic hilum • Spleen enlarged, splenic index 150 • No lymph nodes or mass seen

  33. S/Electrolytes: • S/Na: 135 mmol/l • S/K: 3.7 mmol/l • S/Ca: 8.3 mg/dl • S/PO4: 2.3 mg/dl • VIRAL MARKERS: • HBsAg: -ve by ELISA • Anti-HCV: +ve by ELISA

  34. Mild ascites present • Small amount of interloop fluid present • CXR-PA view: • Normal heart size, clear angles, and no active or old lung pathology seen

  35. UPPER GI ENDOSCOPY: • No varices visualised at lower end of esophagus/fundus of stomach • No bleed, or ulcer visualized in the stomach or 1st or 2nd part of duodenum • No mass visualized in esophagus, stomach or duodenum

  36. BONE MARROW BIOPSY: • Hypercellular fragments • ERYTHROPOEISIS: • Hyperactive, MEGALOBLASTIC and MICRONORMOBLASTIC picture • Dyserythropoesis with nuclerhexis • Howell jolly bodies seen

  37. LEUCOPOESIS: • Active with normal maturation • MEGAKARYOPOESIS: • Adequate with normal maturation

  38. IRON/FOLATE/B12 STUDIES • Serum Ferritin: 32 ng/ml ( 32-501 ) • Serum B12: 213 pg/ml ( 180-900 ) • Serum Iron: 25 ug/ml ( 25-156 ) • Serum Folate: 3 ng/ml ( 3-17 )

  39. FINAL DIAGNOSIS??? • DOUBLE DEFICIENCY ANEMIA ( IRON/FOLATE AND B12 ) due to • Combined effect of liver disease( folate/B12def) • and blood loss ( source??? )

  40. A CONUNDRUM? • COULD IT BE HYPERSPLENISM???? • QUERY REGARDING MYELOPDYSPLASIA????

  41. IRON/ FOLATE/B12 DEFICIENCY ANEMIAS

  42. IRON DEFICIENCY ANEMIA • Most common anemia world wide • Most common cause is GI bleed • Other causes include: • Increased demand as in pregnancy • Hemoglobinuria • Decreased absorption

  43. Daily intake almost 10-15 mg of iron • Only 10 percent absorbed • Presence of HYPOCHROMIC MICROCYTIC CELLS ON PERIPHERAL SMEAR • ANISOCYTOSIS/POIKILOCYTOSIS • HYERPCELLULAR MARROW, WITH ERYTHROID HYPERPLASIA

  44. TREATMENT • Oral replacement with ferrous sulfate/ ferrous gluconate • I/V replacement where indicated • Treatment to be continued 3-6 months after hemoglobin and indices return to normal

  45. B12 DEFICIENCY ANEMIA • Liver stores adequate, dietary deficiency very rare • Is present in meat • Takes years for deficiency to develop if with dietary deficiency

  46. Other causes: • 1. Decreased absorption: • Achlorhydria • Partial or total gastrectomy • Pernicious anemia • Gut infestation with fish tape worm • Helicobacter pylori infection • 2. Structural intestinal disease: • Chron’s disease • Surgical resection of gut

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