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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: –Prior history of alcohol abuse (20 beers per day). Last use 2 years ago –No tobacco or illicit drug use Family History: Non-contributory Medications: –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: ) TIBC: 462 mcg/dL (nl: ) Ferritin: 4.8 ng/mL (nl: ) 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