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CLINICOPATHOLOGICAL CASE. Nilofar Rahman , PGY 3. History of Present Illness. 43 y/o C aucasian M presented with c/o intermittent diarrhea for last 1 month, associated with lower abdominal cramps. - PowerPoint PPT Presentation
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CLINICOPATHOLOGICAL CASE
Nilofar Rahman, PGY 3
43 y/o Caucasian M presented with c/o intermittent diarrhea for last 1 month, associated with lower abdominal cramps.
Stools are liquid, watery, brown in color 3-4 episodes per day not mixed with blood or mucous. No tenesmus. No h/o fever, chills, nausea or vomiting.
No h/o sick contacts or recent antibiotic use.
Stool studies done initially- Ova and parasite- negative, C diff- negative, Culture- negative, Leuko-test- positive.
Empirically treated with Metronidazole- got better for 3 days and again started having diarrhea and cramps .
History of Present Illness
CONSTITUTIONAL: Fatigue. No fever, chill, anorexia, weight loss or night sweats insomnia.
HEENT: No changes in vision or hearing, hoarseness, epistaxis, postnasal drip, vertigo, or recurrent sinusitis.
CVS and RS: Denies chest pain, palpitations, claudication, edema, phlebitis, dyspnea, orthopnea, cough, asthma, or pneumonia.
GI: Intermittent diarrhea and abdominal cramps. Denies dysphagia, early satiety, heartburn, vomiting, excessive flatus. melena, rectal bleeding, hemorrhoids or laxative abuse.
GENITOURINARY: Denies dysuria, urinary frequency, urgency, nocturia, hematuria.
MUSCULOSKELETAL: Chronic Muscle pain, joint pain. Denies decreased range of motion, arthritis, back pain, morning or night cramps.
INTEGUMENTARY: Denies changes in skin lesions, presence of unusual skin lesions, pruritus, nail changes, hair changes.
NEUROLOGIC: Denies headaches, dizziness, paraesthesias, weakness, fainting, coordination difficulty, cranial nerve problems, or gait disturbance.
Review Of Systems
Past Medical and Surgical History◦ Significant for history of foot surgery when he was young.
◦ Arthritis, joint pain. History of trigger fingers.
◦ History of allergies
Social history◦ Does not smoke, drinks maybe 6 beers a week. He works as a janitor . Married,
has 3 children.
Family history◦ He does not know much. He is adopted.
…CASE
Allergies:◦ PCN- rash as child
◦ Sulfa- rash
Medications:◦ Tramadol as needed
◦ Flonase daily AM
…CASE
Vital signs: Temp-98F, BP 120/90, HR- 64, RR- 16, Weight - 190 Lb HEENT:
◦ Head: Normocephalic with no unusual masses;◦ Ears: No pre or postauricular masses or lymphadenopathy. External auditory canal is within
normal limits. Normal tympanic membrane. ◦ Nose: septum is midline with normal septal mucosa.◦ Oral cavity: unremarkable.◦ Neck: No anterior cervical lymphadenopathy. There are 2 occipital lymph nodes, each
approximately 1 cm soft, mobile, and non tender ( pt stated that the LN are present for >1 year, wax and wane, initially started after an URI). No thyroid enlargement
No axillary lymphadenopathy Chest - Clear to auscultation, no wheezes or crackles.
CVS - S1, S2 heard, RRR. No murmurs, rubs or gallop. Abdomen - Soft, non tender, no rebound or guarding, no signs of peritonitis, BS +ve.
No hepatosplenomegaly. Neurologic: Cranial nerves II through XII are intact and functioning symmetrically.
Motor strength 5/5, and sensations were intact. Symmetrical reflexes. Gait was normal.
Physical Examination
My questions Diarrhea: ?recurrence, alternating with constipation, nocturnal
diarrhea, fasting diarrhea, stools were foul smelling or greasy
PMH: h/o recurrent infections, duration of arthritis
Family history: colon cancer, autoimmune conditions, CAD, DM, IBD
Dietary history: exposure to impure water source, intake of smoked foods, raw milk
Social history: IV drug use, secondary gain from illness, travel, exposure to TB, occupation
Sexual history: promiscuity, h/o STDs
Therapeutic interventions – Radiation, OTC medications
More questions
Rectal exam: anal fissures, fistula, abnormal anal sphincter pressure
Eye exam: evidence of episcleritis
Skin: rashes, erythema nodosum
Exam of joints: range of motion, effusion
WBC 7.3HGB 16HCT 44.9MCV 85.1Platelet 328
Hematology
Neutrophils 61%Lymphocytes 28%Monocytes 8%Eosinophils 1%Basophils 2%
Na 140K 4.2Cl 105CO2 25BUN 16Cr 0.8Ca 9.0
Complete Metabolic Panel
Total protein 7.7Albumin 4.3AST 24ALT 33Alk ph 74T bili 0.5
Other labs
TSH 0.54 (0.35-4.94)ESR 3CRP <0.5Celiac disease panel Negative
CT Scan Abdomen/Pelvis
Filling defect
CT Scan Abdomen/Pelvis
Case summary43 y/o Caucasian M with PMH of arthritis and allergies presented with c/o intermittent diarrhea for one month. Stools were watery, non bloody and associated with lower abdominal cramps.
Initial assessment revealed two palpable, soft, non tender occipital lymph nodes which were 1 cm in size. The lymph nodes were noticed > 1 year ago, waxing and waning type, initially brought about by an URI.
Labs showed some hemoconcentration.
CT scan of abdomen and pelvis revealed filling defect in ileum and abdominal and inguinal lymphadenopathy.
Additional workup
FOBT, stool electrolyte
Baseline Hb and Hct and magnesium levels
Colonoscopy with biopsy
Plasma peptides: Gastrin, Somatostatin
Urine 5HIAA, serotonin
Broad differential diagnosis Inflammatory:
IBD – crohn’s disease
Ischemic colitis
Tumors Benign: adenomas, leiomyomas
and lipomas Malignant
• Adenocarcinoma• Lymphoma
Drugs
Chronic infections: • HIV associated opportunistic
infections• Tubercular enteritis
Secretory diarrhea Laxative abuse Post cholecystectomy Neuroendocrine tumors
• Gastrinoma• Somatostatinoma• VIPoma• Carcinoid syndrome
Malabsorption syndromes Small bowel bact
overgrowth, short bowel syndrome, pancreatic exocrine insufficiency
Disordered motility Hyperthyroidism Diabetic autonomic
neuropathy Irritable bowel syndrome
Drugs causing diarrheaCardiovascular Antiarrhythmics Quinidine,
Procainamide, Digitalis
Antihypertensives ACEi, ARBs, Bblockers, Hydralazine, methyldopa
Cholesterol lowering agents
Statins, cholestyramine, gemfibrozil
Diuretics Acetazolamide, ethacrynic acid, furosemide
Central nervous system AntianxietyAntiparkinsonianOthers
LorazepamLevodopaAnticholinergics, Lithium, floxetine
Endocrine Oral hypogycemicsThyroid replacement
MetforminSynthroid
Drugs causing diarrheaGastrointestinal Antiulcer
Bile acids
Laxatives
H2 blockers, PPIs, mag containing antacids
Ursodeoxycholic acid
Lactulose, sorbitol
Musculoskeletal Gold salts
NSAIDS
Gout
Auronofin
Ibuprofen, naproxen
Cochicine
Antibiotics Ampicillin, amoxycillin, clindamycin, cephalosporins, neomycin
Antineoplastic several
Dietary Alcohol, sugar substitutesVitamins Magnesium,
Vitamin C
Tramadol causes diarrhea in < 5% of cases
Broad differential diagnosis Inflammatory:
• IBD-crohn’s
Ischemic colitis
Tumors Benign: adenomas, leiomyomas,
and lipomas Malignant
• Adenocarcinoma• Lymphoma
Drugs
Chronic infections: • HIV associated opportunistic
infections• Tubercular enteritis
Secretory diarrhea• Laxative abuse• Neuroendocrine tumors
• Gastrinoma• Somatostatinoma• VIPoma• Carcinoid syndrome
Malabsorption syndromes• Small intestinal bact
overgrowth, short bowel syndrome, pancreatic exocrine insufficiency
Disordered motility• Hyperthyroidism• Diabetic autonomic
neuropathy• Irritable bowel syndrome
Ischemic colitisMesenteric ischemia: reduction in blood flow, acute and chronic
Risk factors: h/o smoking, atherosclerotic vascular disease
Chronic mesenteric ischemia is due to episodic or constant hypoperfusion
Symptoms:
Abdominal pain – symptoms out of proportion to signs
Sitophobia – weight loss
Diarrhea
Diagnosis is due by CT or MR angiography
Broad differential diagnosis Inflammatory:
• IBD – crohn’s
Ischemic colitis
Tumors Benign: adenomas, leiomyomas and
lipomas Malignant
• Adenocarcinoma• Lymphoma
Chronic infections: • HIV associated opportunistic
infections• Tubercular enteritis
Secretory diarrhea• Laxative abuse• Neuroendocrine tumors
• Gastrinoma• Somatostatinoma• VIPoma• Carcinoid syndrome
Malabsorption syndromes• Small intestinal bact
overgrowth, short bowel syndrome, pancreatic exocrine insufficiency
Disordered motility• Hyperthyroidism• Diabetic autonomic neuropathy• Irritable bowel syndrome
Other neuroendocrine tumorsGastrinoma: well differentiated NET Duodenum and pancreas Gastrin is predominant peptide Symptoms: peptic ulcers, diarrhea, weight loss Diagnosis: serum fasting gastrin, secretin stimulation test, gastric acid secretion
studies
Somatostatinoma: rare NET of D cell origin – secretes somatostatin Mainly found in duodenum or pancreas
Symptoms: diarrhea with steatorrhea, abdominal pain, diabetes, cholelithiasis
VIPoma: Rare NET, secretes VIP Watery diarrhea, hypokalemia, hypochlorhydria
Imaging of NET CT scan, octreotide scan
Broad differential diagnosis Inflammatory:
• IBD – crohn’s
Tumors Benign: adenomas, leiomyomas and
lipomas
Malignant• Adenocarcinoma• Lymphoma
Chronic infections: • HIV associated opportunistic
infections• Tubercular enteritis
Secretory diarrhea• Laxative abuse• Neuroendocrine tumors
• Carcinoid syndrome• Gastrinoma• Somatostatinoma• VIPoma
Malabsorption syndromes• Small intestinal bact
overgrowth, short bowel syndrome, pancreatic exocrine insufficiency
Disordered motility• Hyperthyroidism• Diabetic autonomic
neuropathy• Irritable bowel syndrome
Irritable bowel syndrome Important cause of functional diarrhea, 2:1 female predominance
Clinical manifestations:• Diarrhea, constipation or alternating bowel habits
• Diarrhea is associated with mucus
• LARGE, VOLUMINOUS, BLOODY OR NOCTURNAL DIARRHEA ARE NOT ASSOCIATED WITH IBS.
Diagnosis by ROME criteria
Broad differential diagnosis Inflammatory:
• IBD – crohn’s
Tumors Benign: adenomas, leiomyomas and
lipomas
Malignant • Adenocarcinoma• Lymphoma• NET: Carcinoid
Chronic infections: • HIV associated opportunistic
infections• Tubercular enteritis
Disordered motility• Irritable bowel syndrome
Inflammatory bowel diseaseCrohn’s disease: transmural inflammation of GI tract
80% ileum 50% ileum and colon
Clinical manifestations:
Abdominal pain Diarrhea with or without bleeding Fistulas phlegmon Perianal disease Other GI involvement: oral ulcers, esophageal, gastroduodenal
and gallstones Systemic manifestations: fatigue, weight loss, fever
Clinical manifestations Extraintestinal manifestations:
Arthritis: large joints or central/axial skeleton
Eye involvement: uveitis, episcleritis, iritis
Skin: erythema nodosum and pyoderma gangrenosum
Primary sclerosing cholangitis
Venous and arterial thrombosis
Renal stones
Vitamin B12 deficiency
Diagnosis of crohn’s disease Iron deficiency anemia, elevated ESR/CRP, Vitamin B12 deficiency,
elevated WBC
Serologic tests: p ANCA, ASCA
Wireless capsule endoscopy
Imaging:
CT abdomen
MRI
Diagnostic accuracy of serological assays in inflammatory bowel disease. Ruemmele FM, Targan SR, Levy G, Dubinsky M, Braun J, Seidman EG. Gastroenterology. 1998;115(4):822.
Diagnosis of crohn’s diseaseColonoscopy findings:
Endoscopic features in Crohn's disease: Aphthous ulcers, which are the earliest lesions seen in Crohn's disease (panel A); large ulcers interspersed with normal mucosa, which are typical for the segmental distribution of Crohn's disease (panel B); a cobblestone appearance (panel C); and strictures due to fibrosis (panel D).
Tumors of small bowel
Types:
Benign: adenomas, leiomyomas and lipomas
Malignant:
Duodenum: adenocarcinoma, carcinoid, lymphoma, sarcoma
Jejunum: adenocarcinoma, lymphoma, carcinoid
Ileum: carcinoid, adenocarcinoma, lymphoma
Adenocarcinomas
Risk factors: Hereditary conditions, crohn’s disease, dietary factors
Clinical manifestations:
abdominal painnausea/vomitinganemiaGI bleed
Carcinoid tumor Arise from intraepithelial endocrine cells Ileum – 60 cm from ileocecal valve Symptoms/signs: asymptomatic, abdominal pain, diarrhea, obstruction Metastasis to liver – carcinoid syndrome
Diagnosis: 24 hr urinary excretion of 5HIAA, urine serotonin Serum chromogranin A, B, C levels CT scan Octreotide scan
CT scan: soft tissue mass containing coarse central calcifications (short arrow) in the RLQ. This is a classic desmoplastic response with spiculation of the adjacent mesenteric fat (long arrow).
Lymphoma May arise as a primary GI lymphoma or as a part of systemic disease
Primary GI tract lymphoma- stomach, small intestine
Risk factors: Autoimmune, crohn’s, immunodeficiency syndromes, chronic immunosuppression, radiation
Classified as• Immunoproliferative small intestinal disease (IPSID)• Enteropathy associated T cell lymphoma (EATL)• Non immunoproliferative small intestinal disease (non IPSID)
Clinical features differ according to histologic type• IPSID: abdominal pain, diarrhea, weight loss• EATL: acute GI bleed, intestinal obstruction or perforation• Non IPSID: abdominal pain, GI bleed, obstruction or perforation
Diagnosis of small bowel tumors Small bowel follow through may show a mass or mucosal defect
CT scan
Endoscopy with biopsy
Tumor markers: CEA
Chronic infections Small bowel manifestation of HIV is enteritis
Opportunistic infections likely occur when CD4 < 50 /microL
Common organisms:
• Bacterial: salmonella, shigella, campylobacter and c. diff
• Parasites like giardia, cryptosporidium, microsporidia, isospora
• Enteric pathogens like mycobacterium avium intracellulare
HIV
Cryptosporidium and microsporidia: transmitted as zoonosis or feco oral
involves small bowel, microsporidia – has extraintestinal involvement
High output diarrhea and malabsorption like vit B12 deficiency
Villous atrophy on biopsy
therapy – under investigation
Isospora: feco oral route of transmission
Acid fast stains – large oocysts, charcot leyden crystals
Biopsy: intracellular forms, eosinophils and villous atrophy
Giardia: diarrhea, severe in those who practice oral-anal sex Stool exam and duodenal aspirates: cysts, trophozoites
HIV CMV: ususally involves esophagus and colon
Mycobacterium avium intracellulare: CD4<100/microL• Fever, weight loss, abdominal pain, diarrhea• Small bowel biopsy: macrophages with acid fast organisms• CT scan: lymphadenopathy with central necrosis
Intestinal involvement – kaposi’s sarcoma – HHV8
NHL: • involves the small intestine • Abdominal pain, diarrhea or mass lesions
Final diagnosis Tumors Benign: adenomas, leiomyomas, lipomas
Malignant • Adenocarcinoma• Lymphoma• NET: carcinoid
Metastatic lesions
Chronic infections: • HIV associated opportunistic infections• Tubercular enteritis
Inflammatory:IBD – crohn’s
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