- Patient presentation
- Differential Diagnosis
- Special investigations
- Evaluation - Questions & answers
Patient is a 22 year old female who presented to the surgery department of a tertiary level hospital having been referred from a private clinic, with a two month history of severe abdominal cramps, persistent bloody and mucoid diarrhoea, weight loss and tiredness.
This case study was kindly provided by Dr Monica Mercer from Immunopaedia
2 months ago:
Symptoms began with abdominal cramps and an intense urge to pass stool after every meal. Her symptoms rapidly worsened with passage of stool becoming more frequent. Within two days she was passing persistently watery diarrhoea mixed with fresh blood and mucous. She was seen by her general practitioner who treated her for gastritis.
One week later she collapsed at home and was admitted to hospital for investigations. She was discharged two days later without a diagnosis.
1 month ago:
Symptoms persisted and she experienced diarrhoea and vomiting after eating or drinking, which lasted for 10 days. She was admitted to hospital for rehydration and further investigations. No conclusive diagnosis was made.
Patient is passing 10-20 liquid stools per day. Diarrhoea is mucoid and bloody. Occurs day and night. Patient complains of malaise, lethargy and anorexia. She has lost 8 kg in the past 2 months.
No past surgical history
No significant medical history
Mother – type 2 Diabetes Mellitus
No other family members with chronic disease
No known allergies
- Clostridium difficile
- If HIV positive consider- MAC, Isospera beli, cryptosporidium, TB
- Functional bowel syndromes e.g. irritable bowel syndrome (IBS)
- Coeliac disease
- Inflammatory bowel disease (IBD)
Thin ill looking young woman, conscious and alert, in obvious discomfort.
Heart rate: 80bpm
Respiratory rate: 18 bpm
Blood pressure: 120/70
Pale mucous membranes
Guarding and tenderness noted in the left iliac fossa and hypogastrium.
No results available from previous admissions. All results are from current admission.
|WCC||5.9 x 10ˆ9/l||(4.00 – 10.00)|
|Hb||9.0 g/dl||(12.1 – 15.1 g/dl)|
|Platelets||748 x 10ˆ9/l||(150 – 400)|
|CRP||17.4 mmol/l||(0 – 10 mmol/l)|
|Urea and Electrolytes:|
|Na||137 mmol/l||(135 – 147 mmol/l)|
|K||3.5 mmol/l||(3.3 – 5.0 mmol/l)|
|Cl||96 mmol/l||(99 – 113 mmol/l)|
|Co2||31 mmol/l||(18 – 29 mmol/l)|
|Urea||3.3 mmol/l||(2.5 – 7.0 mmol/l)|
|Creat||32 umol/l||(60 – 12 umol/l)|
|Liver Function Test:|
|Total Bili||7 umol/l||(3 – 18 umol/l)|
|Conjugated Bili||3 umol/l||(0 – 5 umol/l)|
|Total Protein||56 g/l||(60 – 80 g/l)|
|ALP||66 U/l||(30 – 120 U/l)|
|GGT||15 U/l||(5 – 35 U/l)|
|AST||23 U/l||(5 – 45 U/l)|
|ALT||18 U/l||(5 – 45 U/l)|
|Thyroid Function Test:|
|Free T4||15.1 pmol/l||(10.3 – 21 pmol/l)|
|TSH||1.8 mIU/l||(0.35 – 4.50 mIU/l)|
|Calcium||2.23 mmol/l||(2.12 – 2.65 mmol/l)|
|Phosphate||0.9 mmol/l||(0.8 – 1.4 mmol/l)|
|Aerobic organisms||Not isolated|
|C difficile toxin A||Negative|
|C difficile toxin||Negative|
No toxic megacolon
Oesophagus and gastro- oesopahageal junction were normal. Stomach mucosa was intact and normal. No gastritis, ulceration or blood was noted. Cardia was normal. Pylorus and duodenum normal.
Very friable mucosa. Extensive ulceration with pseudopolyps, involving the rectum, entire sigmoid and left colon up to the transverse colon. Multiple biopsies of the colonic tissue were taken for histological analysis.
Pathology is limited to the mucosa and submucosa. Intense infiltration of the mucosa and submucosa with neutrophils and crypt abscesses, lamina propria with lymphoid aggregates, plasma cells, mast cells and eosinophils, and shortening and branching of the crypts.
Treatment and management:
On admission patient was rehydrated and given Solucortef 100 mg IMI tds.
She continued to pass 10 stools the following day.
Patient continued to experience diarrhoea and unable to tolerate food or water.
Transfused with 2 units of packed cells
Asacol 1.2g po, tds
Asacol suppository PR bds
Morphine 15mg IMI PRN
Flagyl 500mg tds
Patient has continued to experience diarrhoea of watery, bloody stools. Abdominal pain has decreased and abdomen is soft and undistended.
It was decided to continue medical management for a further 7 days, with the addition of:
Cyclosporine 80mg IVI, infused over 2hrs
Losec 20 mg po daily
Slow K rider IVI bds
Slow Magnesium IVI daily
Clexane 40 mg S/C daily
It was decided that medical management had failed as no relief of symptoms was achieved. Surgical management was therefore required.
A laparoscopic total colectomy and ileostomy was perfomred. Three months post surgery the patient is scheduled to return for ileal-anal pouch surgery, to eliminate the need to wear a bag.
Evaluation – Questions & answers
What is the Diagnosis?
How do you grade the severity of the disease?
Symptoms Mild Severe Fulminant
Stools per day 6 >10
Hematochaezia Intermittent Frequent Continuous
Temperature Normal >37.5 C
Pulse Normal >90
Haemoglobin Normal <75% of normal Transfusion
What is the pathogenesis of ulcerative colitis
Microfold (M) cells are specialised epithelial cells of the Peyer’s patches that sample antigens from the gut lumen, thereby enabling the host to respond immunologically. These cells take up intact antigen from the lumen by endocytosis and deliver it to dendritic cells and macrophages for antigen presentation to T lymphocytes. Activated T lymphocytes differentiate into Th1, Th2, Th17 or Treg subclasses that mediate inflammatory responses. Secretion of pro-inflammatory cytokines by activated T lymphocytes may be involved in the disease (See figure 2).
What gene associations occur in ulcerative colitis?
What are Peyer’s patches?