Gastrointestinal Bleeding case 4

A 25-year-old man presents to the emergency department complaining of passing bright red blood per rectum. He reports no prior episodes of gastrointestinal bleeding, but he has had occasional lower abdominal pain and diarrhea for the past ten months. He reports a 7 kg weight Ioss since the onset of these symptoms. He denies sick contacts. On examination, he is febrile with moderate, diffuse abdominal pain to palpation and percussion. Rectal examination is positive for blood.

Q 1

Which of the following is the most likely diagnosis?

/ A. Chronic pancreatitis

/ B. Duodenal ulcer

/ C. Infectious colitis

/ D. Inflammatory bowel disease

/ E. Ischemic colitis

Q 2

A colonoscopy is performed and mucosal ulceration with bleeding extending continuously from the rectum to the cecum is seen. The terminal

ileum is spared. Had the terminal ileum been affected, the patient would have been at risk for which of the following conditions?

/ A. Diabetes mellitus

/ B. Folate deficiency

/ C. Iron deficiency anemia

/ D. Kwashiorkor

/ E. Pernicious anemia

Q 3

At colonoscopy the colonic mucosa appears granular, and is ulcerated. Numerous crypt abscesses and pseudopolyps are observed. Which of

the following is the most likely diagnosis?

/ A. Celiac disease

/ B. Clostridium difficile colitis

/ C. Crohn disease

/ D. Rectal diverticulosis

/ E. Ulcerative colitis

Q 4

Several months pass and this patient's symptoms progress. He continues to have frequent bloody diarrhea and abdominal pain. Abruptly, this

patient experiences the acute onset of severe abdominal pain and is taken to the emergency department by friends. In the emergency

department, he is febrile, and his abdomen is rigid, with severe pain to palpation and percussion. Laboratory findings are consistent with

dehydration. Amylase and lipase are normaI. Which of the following most likely explains this patient's new findings?

/ A. Abdominal aortic aneurysm rupture

/ B. Acute pancreatitis

/ C. Bowel perforation and peritonitis

/ D. Sepsis from fulminant infectious colitis

/ E. Severe ischemic colitis

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Gastrointestinal Bleeding case 4 answers

A1

The correct answer is D. Patients with inflammatory bowel disease can present with a variety of symptoms. While ulcerative colitis and Crohn disease patients may have distinct presentations, mixed presentations are common. Distinguishing Crohn disease and ulcerative colitis is difficult, based on clinical findings. Symptoms typical for Crohn disease include: abdominal pain, fever, diarrhea, weight loss, and anal disease. Symptoms typical for ulcerative colitis include: bloody diarrhea, fever, and weight loss.

Chronic pancreatitis (choice A) presents as epigastric pain that radiates to the back, weight loss, and steatorrhea. In many cases, a history of alcoholism is present. Thus the location of this patient's pain and his lower GI bleeding are not consistent with chronic pancreatitis.

Duodenal ulcer (choice B) may present as epigastric pain, and with severe disease, severe bleeding may be present. Patients with duodenal ulcer rarely have diarrhea and weight loss. Thus this diagnosis is unlikely.

Infectious colitis (choice C) presents as abdominal pain and bleeding. Many infectious agents may cause GI bleeding, including Salmonella, Shigella, Campylobacter jejuni, and E. coli. The chronic nature of this patient's complaints and the lack of sick contacts suggests a different diagnosis.

Ischemic colitis (choice E) presents as acute onset of severe abdominal pain often with copious bright red blood per rectum. On examination, they display the classic finding of "pain out of proportion to examination." They are typically elderly patients with a history of atherosclerotic or embolic disease.

A2

The correct answer is E. Pernicious anemia is a hypochromic, megaloblastic anemia that may be associated with neurologic complications. It occurs as a result of a lack of vitamin B 12. The B12/intrinsic factor complex is absorbed in the terminal ileum by active transport. If this patient's ulcerative colitis extended into the terminal ileum, this condition could complicate his disease. Crohn disease almost invariably affects the terminal ileum, and this malabsorptive condition is more common in that setting. Ulcerative colitis usually affects only the colon, but ileal extension has been observed.

Diabetes mellitus (choice A) is an endocrine condition, and is unrelated to the absorptive capacity of the terminal ileum.

Folate (choice B) is absorbed in the proximal small intestine. Ileal involvement would not affect its absorption.

Iron (choice C) is also absorbed in the proximal small intestine. Ileal involvement would not affect its absorption.

Kwashiorkor (choice D) is protein malnutrition. Protein is absorbed throughout the small intestine. Ileal involvement would not affect its absorption.

A3

The correct answer is E. Granular, flat mucosa with ulcers, crypt abscesses, and pseudopolyps are characteristic findings in ulcerative colitis.

Celiac disease (choice A) is a disease of the intestine resulting from a hypersensitivity to the protein gluten. The intestinal mucosa is smooth and atrophic.

Clostridium difficile colitis (choice B) or "pseudomembranous colitis" is a colonic infection seen after extensive antibiotic use, which disturbs the colonic flora, promoting overgrowth of C. difficile. Fibrinous pseudomembranes are seen in the colon at colonoscopy.

Endoscopic evaluation of Crohn disease (choice C) reveals swollen mucosa with transverse fissures and linear ulcers. Biopsy findings demonstrate transmural involvement with granuloma formation.

Diverticula are outpouchings of the intestinal mucosa. They may bleed, or they may become infected, leading to a painful condition, diverticulitis. The findings here do not suggest diverticulosis (choice D).

A4

The correct answer is C. This patient's chronic course with acute exacerbation suggests that this patient has viscus perforation with peritonitis secondary to exacerbation of his ulcerative colitis. The inflammatory processes in ulcerative colitis can be so severe that erosion from inflammation can cause colonic perforation. Bowel contents then leak into the peritoneal cavity, causing peritonitis. Peritonitis is characterized by fever, severe abdominal pain, abdominal tenderness to palpation and percussion, and rigidity of the abdominal wall.

Abdominal aortic aneurysm rupture (choice A) presents as abdominal pain that radiates to the back. It is accompanied by hemodynamic instability that may deteriorate to shock. This presentation is not consistent with findings in this patient.

Acute pancreatitis (choice B) can cause severe abdominal pain and fever. The pain, however is usually epigastric and radiating to the back. Typically nausea and vomiting accompany pancreatitis. Amylase and lipase are elevated.

This patient does not display the symptoms of sepsis (choice D). In sepsis, patients are febrile with hemodynamic instability.

Ischemic colitis (choice E) can lead to perforation and peritonitis, and if the patient had symptomatology consistent with ischemic colitis, it could be the source of this patient's peritonitis. This patient did not report bright red blood per rectum, or "pain out of proportion to examination," making ischemic colitis less likely.