Download 34-Year-Old Woman With Abdominal Pain and Blood

RESIDENTS’ CLINIC
34-Year-Old Woman With Abdominal Pain
and Blood-Streaked Diarrhea
Carolyn M. Larsen, MD; Kelly M. Nakamura, BS; and Anjali Bhagra, MBBS
A
34-year-old woman presented to the emergency department for evaluation of a 12-hour
history of sudden severe epigastric pain and
bilateral leg weakness during exercise associated with
nausea and vomiting. She experienced 2 episodes of
diarrhea; 1 of which was blood streaked. The patient
reported not eating or drinking much that day. She
described a few previous less severe episodes of abdominal pain and diarrhea since childhood associated
with certain foods. She denied fever or chills but reported
a 5-lb intentional weight loss during the past month. She
denied changes in her appetite, myalgia, arthralgia, or vision changes. She had no recent travel, sick contacts, or
antibiotic drug use. She denied current pregnancy.
The patient was previously healthy; her medical
history included recurrent urinary tract infections
and infertility, with a previous artificial insemination attempt resulting in a missed abortion. Current
medication use includes clomiphene and progesterone vaginal suppository.
At presentation, her vital signs were as follows:
temperature, 36.9°C; heart rate, 69 beats/min; respiratory rate, 16 breaths/min; and blood pressure,
98/60 mm Hg. On examination, the patient appeared uncomfortable but was in no acute distress.
Her abdomen was soft and nondistended, with positive bowel sounds. She had generalized tenderness
in all 4 quadrants, with absence of guarding and
rebound tenderness. Her mucous membranes appeared dry. Lower extremity strength was normal.
Results of a urine pregnancy test obtained on arrival
to the emergency department were negative.
1. Which one of the following tests would be
most appropriate at this time?
a. Fecal occult blood
b. Abdominal radiograph
c. Abdominal ultrasound
d. Abdominal computed tomography (CT)
e. Colonoscopy
Fecal occult blood testing would not be useful
in this patient’s situation. The patient would require
further evaluation, regardless of the results of the
fecal occult blood test. An abdominal radiograph is
useful in cases of acute abdominal pain for quickly
identifying intraperitoneal free air. In this patient,
however, whose examination was nonfocal and
lacked peritoneal signs (absence of guarding and rebound tenderness), an abdominal radiograph is not
the best test to diagnose the cause of her symptoms.
Ultrasonography is an accepted method for the
evaluation of abdominal pain, especially if the gallbladder or a female pelvic pathologic disorder is suspected based on clinical presentation or examination findings. This patient’s presentation (diarrhea
and gastrointestinal [GI] bleeding), her negative
urine pregnancy test results, and the diffuse nature
of her pain on examination do not point toward
either of these causes. If her urine pregnancy test
result had been positive, an ultrasound would have
been an appropriate next step.
An abdominal CT would be the initial imaging
test of choice. Abdominal pain and acute-onset diarrhea raise suspicion for colonic disease in this patient. A CT scan is the preferred initial screening test
to rule out a colonic, versus an extracolonic, pathologic disorder. In addition, it provides information
on all intra-abdominal and retroperitoneal structures.1 In women of childbearing age, a pregnancy
test should be performed before proceeding with
CT. Colonoscopy plays an important role in the
evaluation of GI bleeding. In patients with ongoing
hematochezia, a colonoscopy should be performed
as soon as possible. In patients such as this one, in
whom there is no sign of active bleeding, a colonoscopy can be performed on a semi-elective basis but
would not be the initial diagnostic test.
An abdominal CT showed wall thickening and
inflammation of the distal ileum and splenic flexure.
The patient was admitted to the hospital for further
evaluation. Overnight, her abdominal pain improved, but did not resolve, with supportive therapy. No additional episodes of emesis, diarrhea, or
lower extremity weakness were observed.
See end of article for
correct answers to
questions.
Resident in Internal Medicine, Mayo School of Graduate Medical Education, Mayo
Clinic, Rochester, MN
(C.M.L.); Medical student,
Mayo Medical School, Mayo
Clinic, Rochester, MN
(K.M.N.); Advisor to Residents and Consultant in Primary Care Internal Medicine,
Mayo Clinic, Rochester,
MN (A.B.).
2. Which one of the following tests is the best
test to confirm the suspected diagnosis?
a. Serum lactate level
b. Barium enema radiograph
c. Colonoscopy
d. Flexible sigmoidoscopy
e. Mesenteric angiography
The clinical presentation and CT findings suggest
colitis. The differential diagnosis for the cause of colitis
includes infectious, inflammatory, and ischemic etiologies. Imaging studies are nonspecific and do not differentiate between these etiologies of colitis.2
A serum lactate level could refer to either a serum L-lactate or a serum D-lactate level. An elevated
serum L-lactate level would indicate either tissue
Mayo Clin Proc. 䡲 September 2012;87(9):905-908 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.017
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hypoxia (type A lactic acidosis) or decreased clearance of lactic acid, which occurs most commonly
with liver disease (type B lactic acidosis). D-Lactate is
produced by bacteria in the gut and is metabolized
slowly by humans. Patients with short-bowel syndrome can develop lactic acidosis from elevated serum levels of D-lactate.3 An elevated serum lactate
level would not confirm the diagnosis of colitis or
clarify the underlying etiology.
In the evaluation of suspected colitis, CT has
largely replaced barium enema. A barium enema
would not provide further diagnostic information beyond what is already known from CT, and residual
contrast may hinder further diagnostic evaluations,
such as endoscopy.1,4 Endoscopy is the preferred method
for confirming the diagnosis and cause of colitis.1,2,4 In
this patient, flexible sigmoidoscopy would not allow visualization of the affected areas of bowel; therefore,
colonoscopy is the best test to confirm the diagnosis.
Mesenteric angiography would not be the next step
in the evaluation of colitis. It may play a role in the evaluation of ischemic colitis if there is isolated right-sided colonic involvement (possible superior mesenteric artery
occlusion) or if there is a question as to whether a patient
has mesenteric ischemia or colonic ischemia.1,4
A colonoscopy was performed next and showed
areas of irregular erosion and ulceration starting at
the splenic flexure and involving the distal colon.
The mucosa in the distal ileum, as well as the cecum;
ascending, transverse, and sigmoid colon; and rectum, appeared normal. A biopsy of the area of segmental colitis showed edema and hemorrhage in the
lamina propria and superficial epithelial necrosis.
In patients with findings of colitis on CT, stool
antimicrobial assessment (including Clostridium difficile toxin testing) to assess for infectious colitis is often
completed before proceeding with colonoscopy. In
this case, stool antimicrobial assessment was initiated
but not completed before colonoscopy. The patient’s
ongoing abdominal pain and the distribution of colonic lesions on CT, which raised concern for skip lesions of Crohn disease, led to the pursuit of early
colonoscopy. Stool assessment ultimately revealed few
fecal leukocytes and a negative polymerase chain reaction result for Shiga toxin. The stool cultures for enteric
pathogens were negative for Salmonella, Shigella, Campylobacter, Yersinia, and Aeromonas.
3. Which one of the following diagnoses is
most likely in this patient?
a. Ulcerative colitis
b. Crohn disease
c. Transient ischemic colitis
d. Gangrenous ischemic colitis
e. Infectious colitis
In ulcerative colitis, one would expect to see
mucosal disease (erythema, edema, hemorrhage, or
906
ulceration) starting at the rectum and extending
proximally. Biopsy findings would include diffuse
crypt architectural irregularity and reduced crypt
numbers.5,6 The rectal mucosa was not involved in
this case, making ulcerative colitis unlikely. Crohn
disease could account for the colonic and distal ileal
involvement seen on CT; however, on a colonoscopy one would expect to see a cobblestone pattern
of ulcerations enclosing islands of normal mucosa.5
Biopsy findings would include granulomas and focal
or patchy inflammation.6
Transient ischemic colitis is the most likely diagnosis in this case. The scattered erosions and ulcerations seen on the colonoscopy, combined with
the biopsy findings of superficial mucosal edema,
hemorrhage, and epithelial necrosis, are classic.7
Other findings on the colonoscopy in ischemic colitis include edematous and fragile mucosa, scattered
erythema, purple hemorrhagic nodules, and sharp
demarcation of the area of involved bowel. In severe
forms of ischemic colitis, the mucosa appears cyanotic,
and pseudomembranes, pseudopolyps, and pseudotumors may be seen. In gangrenous ischemic colitis,
bluish-black mucosal nodules may be present.8
The clinical suspicion for infectious colitis was
low in this case because the patient had no recent
travel or dietary history to suggest exposure to enteric pathogens. Furthermore, results of stool studies were negative. The patient was treated supportively for a diagnosis of transient ischemic colitis
based on her colonoscopy and clinical presentation.
Her abdominal pain resolved, and she continued to
remain free of recurrence of diarrhea or GI bleeding.
She did not experience any recurrent lower extremity weakness with ambulation.
4. Which one of the following statements is
true regarding this patient’s disease?
a. It most commonly involves the right
colon.
b. Abdominal pain, GI bleeding, and diarrhea
are the most common presenting
symptoms.
c. Young, healthy persons are at highest risk
for this disease.
d. Male sex is a risk factor for this disease.
e. Cardiac thromboembolism is the most
common cause of this disease.
The right colon is infrequently involved in ischemic colitis. It most commonly involves watershed
areas of the bowel, such as the splenic flexure and
rectosigmoid junction.8 In one series, the splenic
flexure was involved in 57% of patients, and the
sigmoid and rectum were involved in 9%.9 Involvement of the left colon (80%) is much more common
than that of the right colon (4.7%).8
Mayo Clin Proc. 䡲 September 2012;87(9):905-908 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.017
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RESIDENTS’ CLINIC
The most common presenting symptoms of
ischemic colitis include abdominal pain (49%78%), GI bleeding (62%-77%), and diarrhea (33%38%).8,9 Age is a risk factor for ischemic colitis, with
elderly patients being at a higher risk than young,
healthy patients. In addition, females are at higher
risk for ischemic colitis than are males. Other risk
factors include cardiovascular disease, hypertension, chronic obstructive pulmonary disease, constipation, and the use of predisposing medications
(nonsteroidal anti-inflammatory drugs, diuretics,
antihypertensives, laxatives, oral contraceptives, and
anticonvulsants).1,2,8-10 Hypotension and hypovolemia, not cardiac thromboembolism, are the most
common mechanisms by which ischemic colitis
occurs.2
This patient’s clinical presentation with abdominal pain, GI bleeding, and diarrhea is consistent
with a typical case of ischemic colitis. Her young
age, lack of comorbid disease, and absence of predisposing medication use, however, make her case
atypical. She was at risk for hypovolemia secondary
to poor oral intake and exercise when her symptoms
developed, and she was hypotensive at presentation.
Her hypotension and hypovolemia were treated by
intravenous fluid resuscitation with normal saline
on hospital admission. The hypotension responded
to fluid rehydration, with no further recurrence during hospitalization.
5. What should this patient be told about her
prognosis?
a. Most cases improve quickly with
supportive treatment and fully resolve
within a few weeks.
b. Isolated right colon involvement is
associated with better outcomes.
c. Chronic ischemic colitis develops in
approximately 50% of patients.
d. Surgical intervention does not have a role
in the treatment of chronic ischemic
colitis.
e. Long-term anticoagulation is indicated in
the presence of abnormal coagulation
studies.
Most cases of ischemic colitis are of a mild form
(transient ischemic colitis) that resolves with supportive measures, including intravenous hydration, hemodynamic stabilization, discontinuation
of offending medications, bowel rest, and antibiotic drug therapy.2,4 It can be difficult on initial
presentation to distinguish mild forms of ischemic colitis from severe forms that may require surgical intervention. One risk factor for more severe
disease associated with worse outcomes is rightsided colonic involvement.11
Eighteen percent of patients develop chronic
ischemic colitis.11 They may experience diarrhea,
protein-losing enteropathy, or GI bleeding, and
their disease may progress to stricture formation or
gangrene.4 Malnutrition from protein-losing enteropathy and symptomatic stricture are indications for
surgical intervention in patients with chronic ischemic colitis.2
The role of hypercoagulable states in the pathogenesis of ischemic colitis is unclear. There is no
evidence that diagnosing and treating a hypercoagulable state in a patient with an initial episode of colonic ischemia is beneficial.
This young woman was treated conservatively
with intravenous fluids and morphine. She was
counseled regarding the importance of maintaining
adequate hydration before, during, and after exercise. She was discharged from the hospital and did
not report recurrence of abdominal pain or bloody
diarrhea during 1-year follow-up.
DISCUSSION
Ischemic colitis is a relatively uncommon condition,
occurring at an incidence of 4 to 44 cases per
100,000 person-years in the general population,
with a higher incidence in patients older than 65
years.10 In the young woman described in this case,
ischemic colitis was not considered the most likely
diagnosis on initial evaluation. The early CT findings of colitis involving the distal ileum and colon
suggested an inflammatory etiology, namely, Crohn
disease. Colonoscopy proved invaluable in making
the diagnosis, as the pathologic findings in inflammatory and ischemic colitis are distinct. With the
correct diagnosis, we were able to provide appropriate treatment for this patient.
Most cases of ischemic colitis are mild in severity and resolve with conservative therapy. Of patients whose disease initially resolves, 13% experience a recurrence of ischemia.12 Approximately
20% of patients with ischemic colitis have severe
disease and, ultimately, require surgical intervention.4,12 Risk factors for severe disease include rightsided colonic involvement, peripheral vascular disease, atrial fibrillation, tachycardia, absence of GI
bleeding, intensive care unit admission, requirement for vasopressor therapy, mechanical ventilation, intraperitoneal fluid on CT, and an increased
serum L-lactate level at presentation.12 Clear indications for immediate surgical intervention include
peritonitis and pneumoperitoneum.12 Fortunately,
this patient remained hemodynamically stable in the
hospital, and her symptoms resolved with conservative therapy.
This case raised a question as to the role of hypercoagulable states in ischemic colitis. Although
there is no evidence that diagnosing and treating
Mayo Clin Proc. 䡲 September 2012;87(9):905-908 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.017
www.mayoclinicproceedings.org
907
MAYO CLINIC PROCEEDINGS
hypercoagulable states in patients with colonic ischemia is beneficial, expert consensus still favors oral
anticoagulation in patients with severe or recurrent
ischemic colitis in whom thromboembolism, secondary to a hypercoagulable state, is the most likely
cause.2 Hypercoagulable states may play a larger
role in younger individuals, such as this patient
without other risk factors for colonic ischemia. Further study in this area is needed. We hypothesized
that our patient’s transient ischemia was secondary
to hypotension and hypovolemia, occurring with
exercise and inadequate hydration and did not
screen for hypercoagulable states. If she were to develop recurrent ischemia, it would be reasonable to
screen for hypercoagulable states at that time and
treat with anticoagulation if present.
Correspondence: Address to Anjali Bhagra, MBBS, Division
of Primary Care Internal Medicine, Mayo Clinic, 200 First St
SW, Rochester, MN 55904 ([email protected]).
REFERENCES
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CORRECT ANSWERS: 1. d. 2. c. 3. c. 4. b. 5. a
Mayo Clin Proc. 䡲 September 2012;87(9):905-908 䡲 http://dx.doi.org/10.1016/j.mayocp.2012.03.017
www.mayoclinicproceedings.org