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Hematochezia University of Pennsylvania Department of Surgery HPI Julie K. is a 32-year-old lady who presents to her primary h i care physician h i i with ith a four f week k history of passing bloody bowel movements. History What other points of the history do you want to know? History Consider the following: • Characterization of Symptoms • Temporal sequence • Alleviating / Exacerbating factors: • Associated Signs & • • • • • Symptoms Pertinent PMH ROS MEDS Relevant Family Hx Hx. Relevant Social Hx. History Julie K. History, K Characterization of Symptoms and Temporal Sequence of Events – Patient noticed bright red blood in her stool b i i 4 weeks beginning k ago, sometimes ti mixed i d with ith mucous. Her bowel movements have been loose but formed. – She has approximately 3 bowel movements daily and often feels an urgent need to d f defecate. – She has also noticed intermittent crampy abdominal pain and a decrease in appetite over the past month. History Julie K. History, K Alleviating/Precipitating g p g Factors – Abdominal pain often worsens with eating – Nothing g alleviates symptoms y p Associated Symptoms – No Nausea or Vomiting – Decreased Appetite – Weight loss of about 10 lbs over past month History Julie K. History, K Has this happened before? – She has experienced abdominal pain and bloody diarrhea twice in the past year but never lasting more than 2-3 days Sick Contacts and Travel History – No known sick contacts – No N recentt ttravell outt off the th country t Additional History, History Julie K. K PMH – None PSH – Appendectomy at age 9 Meds: – None N Additional History, History Julie K. K Family History – Several family members have had intestinal problems” problems “intestinal Social History – Smoked S k d ½ pack k per d day ffor 10 years until 2 years ago, social ETOH consumption no other drug use consumption, – Sexually active in monogamous relationship What is you Differential Di Diagnosis? i ? Differential Diagnosis Based on History and Presentation Inflammatory Bowel Disease – Crohn’s Disease – Ulcerative Colitis Infectious Colitis Parasites: Strongyloidiasis Strongyloidiasis, Amebiasis Rectal or Colon Cancer or Lymphoma Diverticulitis Radiation Enteritis Gastroenteritis G t t iti Ph sical Examination Physical E amination Wh t specifically What ifi ll would ld you look l k for? f ? Physical Examination Examination, J.K. JK Vital Signs: T = 37.3, P = 86, BP = 110/76, RR = 14 Appearance: thin, pale, but in no acute distress HEENT: Sclera anicteric, anicteric mucous membranes pink and moist Heart: RRR Lungs: mild rales at bases Abdomen: normoactive BS,, non-distended,, mildly tender throughout, no guarding or rebound tenderness Rectal: stool in vault mixed with bright red blood blood, no masses, no external anal lesions Differential Diagnosis Would you like to update your differential? Laboratory What would y you obtain? L bR Lab Results lt 10 9 10.9 6.7 225 138 108 12 32.3 98 3.7 MCV = 82% LFTs WNL PT/PTT WNL Stool O&P negative C. difficile toxin negative 24 0 24.0 07 0.7 Laboratory ResultsDiscussion Normal WBC – infection less likely y Mild Anemia – likely from GI bleeding with chronic blood loss given low MCV Electrolytes - Normal C. C difficle diffi l toxin t i negative ti - sensitivity iti it iis 80 8099% based on assay with specificity of 99% making infection with ith C C. difficile highly highl unlikely What are the Next Steps in Diagnosis and Management? Further Diagnosis and Management • Interventions? • Imaging? • Endoscopy? Abdominal X-Ray X Ra X-ray interpretation • Normal abdominal film • No colonic dilatation • No signs of small bowel obstruction or ileus Colonoscopy What would you expect to see? Colonoscopy Colonoscopy findings Colitis • • • Friable, Ulcerated Mucosa Mucosal Edema and Erythema Hemorrhagic g Colonoscopy Continuous inflammation of colonic mucous involving rectum and extending to the splenic flexure and into the early transverse colon Mucosa is erythematous erythematous, edematous edematous, and friable Pseudopolyps – inflammatory, inflammatory nonnon neoplastic mucosal projection Mucosal Biopsy demonstrates distortion of architecture with crypt branching, crypt g inflammatory y cells,, abscess containing ulceration; no granulomas Diagnosis Ulcerative Colitis What next? Medical Management for Mild-to-Moderate Ulcerative Colitis 5-ASA agents – oral and rectal preparations Oral Corticosteroids 6-MP/Azathioprine Medical Management Julie K K. Julie K K. is started on Sulfasalazine 1g TID and also given a course of steroids Her symptoms improve dramatically over the next few days She Sh maintains i t i S Sulfasalazine lf l i th therapy ffor disease control despite minimal symptoms Julie K K. returns Julie K. K now presents to the emergency department 3 weeks after completing the steroid taper taper. She began having crampy abdominal pain and bloody diarrhea 2 weeks ago increasing in severity over the past 5 days. History, Julie K. Characterization of Symptoms and Temporal Sequence of Events – Abdominal pain began gradually 2 weeks ago, was intermittent and crampy, but now worsening in severity and constant – Diarrhea also began 2 weeks ago. It was watery and mixed with bright red blood. Over th pastt 5 days the d patient ti t has h noted t d more blood bl d iin the toilet bowl. – She has been having g >10 Bowel movements daily – Today diarrhea is less than it has been the day before History Julie K. History, K Alleviating/Precipitating Factors – She attempted to take over-the-counter antidiarrheal agents without relief – Patient P ti t feels f l worse with ith eating; ti she h h has avoided oral intake for the past week Associated Symptoms – Subjective fevers and chills – Dizziness, Dizziness particularly on standing – Nausea, but no vomiting – No joint pain, pain no visual changes or eye pain Physical Examination, Julie K. V.S:. T=38.7°C, BP=104/60 (seated), 90/50 (standing), HR=102 (seated), 116 (standing) General: thin, uncomfortable HEENT: sclera anicteric, mucous membranes dry, y no oral lesions Cardiovascular: tachycardic, normal S1 S2, S1, S2 grade II/VI systolic flow murmur Physical Exam Lungs: Clear to Auscultation Bilaterally Abdominal Exam: Hypoactive BS, mildlyy distended, soft, diffuselyy tender but without rebound or guarding Rectal: no external anal lesions lesions, heme + stools Extremities:trace pedal edema Diff Differential ti l Diagnosis Di i Would y you like to update p your y differential? Laboratory What would you obtain? Lab Results 8.9 300 28 PMN’s =80% MCV = 80.1 LFTs WNL PT/PTT normal 140 111 37 2.9 18 1.3 VBG: 7.35/35/40 AG= 10 Lactate: 1 1.1 1 Cultures and Stool Studies pending Laboratory ResultsDiscussion Leukocytosis y – consistent with inflammation, could indicate infection Anemia – indicative of blood loss, likely acute on chronic blood loss given low MCV Mild Non-anion gap Metabolic Acidosis with appropriate respiratory compensation – seen in the context of diarrhea Hypokalemia – GI losses and volume depletion Interventions at this point? Consider the following I Immediate di t Interventions I t ti Admit to Hospital NPO Fluid Resuscitation with Isotonic Crystalloid • (NS LR (NS, LR, or Plasmalyte) Correct Electrolyte Abnormalities Stop St any narcotic, ti antidiarrheal, tidi h l or anticholinergic agents Begin IV Corticosteroids Studies Do you want any further studies? Abdominal X-Ray X Ray Abdominal X-ray Discussion Dilated Dil t d C Colon l g Toxic Megacolon – Dilation of Transverse or Ascending Colon >6cm – No small bowel pathology Colonoscopy py - Discussion Generally avoided during fulminant presentations of colitis Mayy be used cautiouslyy to determine presence of ischemic or pseudomembranous colitis Minimize insufflation used Should not be performed when there is colonic dilation and is contraindicated for cases of toxic megacolon Abdominal CT (not necessary) Abdominal CT - Interpretation Severe Colitis – Diffuse Colonic Wall Thickening with S b Submucosal l Ed Edema – Pericolic Stranding – Ascites Medical Management of Severe Ulcerative Colitis Cyclosporine – Calcineurin inhibitor – Administer 2 2-4mg/kg/day 4mg/kg/day as continuous IV infusion if patient not responding to IV corticosteroids Infliximab – Monoclonal antibody to TNFα – Administered as IV infusion Hospital Course Symptoms do not improve on steroids and cyclosporine She continues to experience bloody diarrhea and worsening abdominal pain. Final Diagnosis Ulcerative Colitis complicated by Fulminant Colitis with Toxic Megacolon What next? Management Continue Supportive pp Therapy py Medical Management – Broad spectrum antibiotics – will treat any infectious component and also offer coverage should p perforation occur – Continue IV corticosteroids Bowel Decompression: NG tube Prepare for Surgery Indications for Surgery Perforation Uncontrolled Bleeding Progressive Dilation Worsening Symptoms Failure to Improve with Medical Management within 24 hours * Delay in surgical intervention leading to emergent surgery is associated with increased morbidity and mortality. Surgical g Options p Subtotal Colectomy y and End Ileostomy (leaving rectal stump) Total Proctocolectomy with Ileal P Pouch–Anal h A lA Anastomosis t i (IPAA) Subtotal Colectomy y Remove diseased colon Create ileostomy Allow toxic state to resolve Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) at a later date Discussion Serious Complications of fulminant presentations of Ulcerative Colitis include: – Massive Hemorrhage – Perforation – Toxic T i Megacolon M l Toxic Megacolon is defined as colonic distension >6cm 6c in the t e presence p ese ce o of a an act active e inflammatory a ato y process. Though most commonly associated with IBD, toxic megacolon may also complicate infectious colitis including Pseudomembranous colitis. Discussion Diagnosis – There may be a history of Ulcerative Colitis, but approximately 10% of patients will present initially with fulminant colitis. – Historyy usually y includes cramping p g abdominal pain, increased bowel movements, and stool mixed with blood and d mucous. – There is often leukocytosis, anemia, and electrolyte disturbances disturbances. Discussion Diagnosis – If toxic megacolon occurs, dilated colon will be visible on abdominal x-ray y and CT. CT is a good non-invasive modality for identifying subclinical complications of fulminant colitis such as perforations and abscesses. – Colonoscopy should be used with care when disease is active and is contraindicated if colon is dilated or patient has fulminant colitis Discussion Management g – Non-surgical management includes aggressive fluid resuscitation, correction of electrolyte abnormalities, b liti administration d i i t ti off b broad d spectrum t antibiotics, and in the case of IBD (ulcerative colitis or Crohn’s disease), ), administration of corticosteroids – Additional medical management may include i immune modulator d l therapy h with i h cyclosporine l i or infliximab Discussion Management – Surgery S is i iindicated di t d when h signs i and d symptoms t fail to improve with medical management or worsen – Emergent Surgery is also warranted in the setting of perforation, hemorrhage, progressive dil ti or toxic dilation t i megacolon. l – Surgical Management: subtotal colectomy with end ileostomy for emergency situations end-ileostomy QUESTIONS ?????? References Baumgart DC, Sandborn WJ. “Inflammatory Bowel Disease: clinical aspects and evolving therapies.” Lancet. 2007;369:1641-57. Cima RR and Pemberton JH JH. “Surgical Surgical Indications and Procedures in Cima, Ulcerative Colitis.” Current Treatment Options in Gastroenterology. 2004;7:181-190 Modigliani, R. “Medical Management of Fulminant Colitis.” Inflammatory Bowel Diseases. Diseases 2002;8(2):129-134. 2002;8(2):129 134 Bullard KM, Rothenberger DA. “Colon, Rectum & Anus.” Schwartz's Principles of Surgery. 8th Edition. S. Ian Gan and P.L. Beck. “A New Look at Toxic Megacolon: g An Update and Review of Incidence, Etiology, Pathogenesis, and Management.” The American Journal of Gastroenterology. 2003;98(11):2364-2371. H, Panthel K K, Bader RD RD, Schmitt C C, Schaumann R R. Rüssmann H “Evaluation of three rapid assays for detection of Clostridium difficile toxin A and toxin B in stool specimens.” Eur J Clin Microbiol Infect Dis. 2007 Feb;26(2):115-9 Strong, Strong Scott. Scott “Fulminant Fulminant Colitis: the case for operative management management.” Inflammatory Bowel Diseases. 2002;8(2):135-137.
