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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 • 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 percutaneous stenting of the RCA • Past Surgical History: Denies • Social History: • Family History: Non-contributory • Medications: • – Prior history of alcohol abuse (20 beers per day). Last use 2 years ago – No tobacco or illicit drug use – – – – – – – – 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