A 44 year old male with unexplained weight loss, intermittent abdominal pain, bloody diarrhea that began 5 months ago shows up in my office. His bloody stool resolves for 1-3 weeks then recurs. Episodes have been less than a week and resolve without seeking medical attention. (I don't know about you but I think I might get help after just ONE bloody D.) Abdominal pain is often sharp and localized to lower abdomen, right side more than left. Denies nausea or vomiting. Diet is unchanged and eating doesn't affect the pain. Weight loss has been approx 15 lbs over 5 months.
Has been using Immodium (suppression)
Intermittently achy ankles, knees, wrists.
Sexually active, no GU complaints.
Had cholecystectomy for gall stones (indicates something about his diet)
Smokes 1/2 packs/day for 15 years
Drinks 2-6 beers "only on weekends"
Drinks 1-3 cups coffee/day
Denies recreational drug use
Father has coronary artery Dz, mother and sis have irritable bowel syndrome
Parents are middle eastern Jews
Pt appears thin
HEENT exam: 2 apthous ulcers in oral cavity
Cardio & lung auscultation: WNL
Abdominal exam: abdomen is flat and nontender, no rebound tenderness
Bowel sounds: very active
No hepatosplenomegaly is noted
Back exam: vertebral spines nontender, costovertebral angles nontender
Rectal exam: small fistula observed at anus. No hemorrhoids visualized or palpated.
Stool contains bright red blood and apparent mucus. Hemoccult positive
hemocult = trademark for a guaiac reagent strip test for occult blood.
occult blood = present in such small amounts as to be detectable only by chemical tests or by spectroscopic or microscopic examination
Why would one test for invisible blood when there is visible blood?
back to the case
CBC reveals mild hypochromic, mycrocytic anemia, WBC's normal
hypochromic anemia = anemia in which the decrease in hemoglobin is proportionately much greater than the decrease in number of erythrocytes.
microcytic anemia = RBC's are smaller than normal
multichem panel: normal
urine analysis: normal
stool culture: PENDING
Sent pt to gastroenterology for colonoscopy, report as follows: The large bowel shows intermittent areas of chronic inflammation with several fissusres noted int he descending bowel and the terminal ileum. areas around the 4 fissure sites all have an acute inflammatory appearance. There is notable sharp demarcation of normal appearing bowel and diseased bowel. The gastroenterologist refers to this as "skin lesions". Biopsy from two sites returns with findings of transmural inflammation which is not confined to the mucosa and submucosa. Noncaseating granulomas are evident within the biopsy specimen.