NYU Medical Grand Rounds Clinical Vignette

Benjamin Wu, MD

PGY-2

May 15, 2012

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

The patient is a 61 year-old woman, presents to an outside physician complaining of black colored stools for 1 week and dyspnea on minimal exertion.

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• The patient had chronic, watery diarrhea related to past history of gastric bypass in the 1970s.

•Patient reportedly with colonoscopy 5 years prior to admission with a “few” polyps with unknown biopsy results

•1 week prior to admission, had bilateral ureteral stents placed for nephrolithiasis, and at that time started on iron supplementation. Hemoglobin was noted to be 8g/dl

• Since that admission, complained of dyspnea with slight exertion, and blackish stools, presented to PMD where a work up found a hemoglobin of 6g/dl

•Referred to Tisch hospital for further evaluation

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

•Past Medical History:• Chronic Obstructive Pulmonary Disease • Chronic Watery Diarrhea

•Past Surgical History:• Gastric Bypass Surgery in the 1970s

•Social History:• Ex-tobacco smoker, 40 pack year smoker• quit 1 year ago • Denies alcohol use • No recent travel • Works as a pet driver

•Family History:• Father had a MI• Mother with history of breast cancer

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Allergies: • Penicillin – rash

•Medications• Ferrous Sulfate 325mg by mouth daily• Lomotil by mouth daily• Pancrease 2 tabs by mouth three times daily• Metronidazole 500mg by mouth three times daily

Physical Examination

•General: Well appearing, well nourished female in no acute distress

•Vital Signs: T: 97F BP: 156/64 HR: 108 RR: 20 and O2 sat: 98% on room air• Pale conjunctiva, tachycardia, regular rhythm, without m/r/g, no gum bleeding, no blood from rectal vault. Positive fecal occult blood.

• The rest of the exam was normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Laboratory Findings

• CBC:•Hemoglobin 5.7mg/dL MCV 82.7, Reticulocytes 8.6%•WBC 13.3 (N77%, L18%, M3%, E1%, B1%)

•Basic Metabolic: Creatinine 1.7mg/dl

•Hepatic: Albumin 3.4g/dl and Total protein 6.1g/dl

•Ferritin 13ng/ml (12-150ng/ml)•Iron 17ug/dl (50-170ug/dl)•TIBC 522ug/dl (250-370ug/dl)•Transferrin Sat 3% (15-50%)

• UA +large blood, protein 30, +small leukocyte esterase, moderate bacteria

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Other Studies

•ECG: NSR

•Chest X-Ray: Clear, without consolidation, no pneumothorax or pleural effusion

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Acute gastrointestinal hemorrhage secondary to possible:– Colorectal cancer– Peptic ulcer disease– Infectious or ischemic colitis – Mesenteric ischemia

Differential Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Transfused blood products and remained hemodynamically stable without further evidence of hemorrhage.

• CT Abdomen/Pelvis without contrasted significant for bilateral staghorn calculi, no evidence of retroperitoneal bleed

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Colonoscopy revealed “frond-like, villous, fungating, ulcerated non-obstructing medium-sized mass in the mid-ascending colon, and two smaller lesions in the proximal transverse colon and cecum.”

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• CT of Abdomen/Pelvis and Chest with IV contrast performed after resolution of acute kidney injury:– hepatic flexure mass with adjacent lymph

nodes. No evidence of metastatic disease.

• 1 month after admission patient underwent right hemicolectomy which revealed a 2.5cm x 2.2 cm lesion with 3/15 positive lymph nodes

Hospital Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Adenocarcinoma of colon, moderately differentiated with focal mucin production

• Stage III

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS