1. Pediatric Case Discussion 2006. 8. 29 R3 吳宜芳 Supervisor: 張玉喆 醫師

2. Case 1 陳 X 男 4983958 陳 X 男 4983958 Age: 3y4m/o, Gender: male Age: 3y4m/o, Gender: male BW: 15 kg BW: 15 kg 基隆急診, 就診時間 :2006/8/5 08:52 基隆急診, 就診時間 :2006/8/5 08:52 Vital signs: TPR:36.7C/ 126/ 20, BP: ?/?mmHg Vital signs: TPR:36.7C/ 126/ 20, BP: ?/?mmHg GCS: E4V5M6, SaO 2 :99% GCS: E4V5M6, SaO 2 :99% 檢傷主訴 : 病患家屬主訴發燒 檢傷主訴 : 病患家屬主訴發燒

3. Case 1 Chief complain: Chief complain: Fever since yesterday Fever since yesterday Present illness: Present illness: intermittent abdominal pain intermittent abdominal pain diarrhea for once yesterday diarrhea for once yesterday no currant jelly stool noted no currant jelly stool noted Past history: Past history: no known drug allergies no known drug allergies no other systemic diseases no other systemic diseases

4. Case 1 Physical examination: Physical examination: Appearance: irritable crying Appearance: irritable crying HEENT: neck supple HEENT: neck supple Chest: coarse breathing sound Chest: coarse breathing sound Heart: RHB Heart: RHB Abdomen: soft, no tenderness Abdomen: soft, no tenderness no palpable mass no palpable mass Extremities: freely movable Extremities: freely movable Initial impression: Initial impression: Abdominal pain, r/o AGE Abdominal pain, r/o AGE

5. Case 1 1. What more do you want to know about this patient and his discomforts? 2. How do we perform physical examination? What should be noticed?

6. Case 1 Chief complain: Chief complain: Fever since yesterday Fever since yesterday Present illness: Present illness: intermittent abdominal pain intermittent abdominal pain diarrhea for once yesterday diarrhea for once yesterday no currant jelly stool noted no currant jelly stool noted Past history: Past history: no known drug allergies no known drug allergies no other systemic diseases no other systemic diseases

7. Case 1 Physical examination: Physical examination: Appearance: irritable crying Appearance: irritable crying HEENT: neck supple HEENT: neck supple Chest: coarse breathing sound Chest: coarse breathing sound Heart: RHB Heart: RHB Abdomen: soft, no tenderness Abdomen: soft, no tenderness no palpable mass no palpable mass Extremities: freely movable Extremities: freely movable Initial impression: Initial impression: Abdominal pain, r/o AGE Abdominal pain, r/o AGE

8. Present illness Chief complain: Fever since yesterday fever up to? Present illness: intermittent abdominal pain onset? the quality and location? Episodic? chronic? diarrhea for once yesterday watery diarrhea? mucus? blood? no currant jelly stool noted Vomiting? quality and quantity? Blood? Billious vomiting ? progress with time? Cough? Dysuria? Headache? Trauma? Diet? Activity? LMD visit? Medication? Past history: no known drug allergies no other systemic diseases previous op?

9. Physical examination Physical examination: Physical examination: Appearance: irritable crying Appearance: irritable crying HEENT: neck supple HEENT: neck supple ear drum? throat? Conjunctiva? LAP? Jaundice? Chest: coarse breathing sound Chest: coarse breathing sound Heart: RHB Heart: RHB Abdomen: soft, no tenderness Abdomen: soft, no tenderness bowel sounds? no palpable mass no palpable mass op scar? inguinal mass? Extremities: freely movable Extremities: freely movable skin rash? Initial impression: Initial impression: Abdominal pain, r/o AGE Abdominal pain, r/o AGE

10. Case 1 8/5 9:00am KUB 8/5 9:00am KUB Discharge or not? Discharge or not? Increased small bowel gas Decreased A-colon gas Rectum gas(+) Hyperdensity shadow clear lung base

11. Case 1 Discharge 13:42 (4hr50mins later) Discharge 13:42 (4hr50mins later) Lactobacillus 1/2 # bid, po Dimethicon 2ml tid, po Kaopectin 6cc qid,po MBD

12. Case 1 2nd ER visit 2006/8/6 18:10 (33hrs later) 2nd ER visit 2006/8/6 18:10 (33hrs later) vital signs: TPR:36.7/145/21, BP:142/90mmHg vital signs: TPR:36.7/145/21, BP:142/90mmHg GCS: E4V5M6, SaO 2 :98% GCS: E4V5M6, SaO 2 :98%檢傷三級 主訴 : 病患主訴因腹痛腹瀉 主訴 : 病患主訴因腹痛腹瀉 Chief complain: Chief complain: intermittent abdominal pain since yesterday intermittent abdominal pain since yesterday

13. Case 1 Present illness: Present illness: intermittent abdominal pain, interval:10+ minutes intermittent abdominal pain, interval:10+ minutes diarrhea for once two days ago, no vomiting diarrhea for once two days ago, no vomiting no fever, no cough no fever, no cough Crying(+), fair activity Crying(+), fair activity 昨天早上來 ER, 下午回家之後有吃 昨天早上來 ER, 下午回家之後有吃 decreased appetite, water intake: OK, decreased appetite, water intake: OK, Urine amount: OK Urine amount: OK Physical examination: Physical examination: HEENT: throat not injected HEENT: throat not injected Abdomen: soft, epigastric tenderness Abdomen: soft, epigastric tenderness no palpable mass no palpable mass

14. Case 1 Case 1 8/6 18:19 KUB Decreased A-colon gas remained Small bowel gas 減少  1. obstruction relief ? 2. 小腸內充滿液體 ? Obstruction progressed ? Rectum gas(+)

15. Case 1 Does the patient have AGE? Does the patient have AGE? What ’ s the differential diagnosis? What ’ s the differential diagnosis? What more can we do to help? What more can we do to help?

16. Differential diagnosis AbdominalNonabdominal AGE Stool impaction UTITraumaIntussusception Appendicitis Incarcerated hernia paralytic ileus Peritonitis Obstruction due to previous op Henoch-Sch ö nlein purpura Pneumonia Myocarditis, pericarditis Diabetic ketoacidosis

17. Case 1 8/6 18:37 CBC,D/C,CRP,U/A IV with D5 1/4S run 60cc/hr Bedside abdominal echo

18. Case 1 CBC, D/C 2006/08/06 1915 WBC 8.9 1000/cmm 6.7~11.8(>1Y-4Y ) WBC 8.9 1000/cmm 6.7~11.8(>1Y-4Y ) RBC 5.04 milon/cmm 4.28~5.05(6M-6Y ) RBC 5.04 milon/cmm 4.28~5.05(6M-6Y ) HGB 13.9 g/dL H 11.6~13.7(3M-6Y ) HGB 13.9 g/dL H 11.6~13.7(3M-6Y ) HCT 39.9 % H 34.2~39.8(6M-6Y ) HCT 39.9 % H 34.2~39.8(6M-6Y ) MCV 79.2 umm 74.9~ 84.6(6M-6 Y) MCV 79.2 umm 74.9~ 84.6(6M-6 Y) MCH 27.6 pg/Cell 25.2~29.1(6M-6Y ) MCH 27.6 pg/Cell 25.2~29.1(6M-6Y ) MCHC 34.8 g/dL 32.6~35.1(6M-6Y ) MCHC 34.8 g/dL 32.6~35.1(6M-6Y ) RDW 12.8 % 11.5-14.5 RDW 12.8 % 11.5-14.5 PLATELET 287 1000/cmm 150-400 PLATELET 287 1000/cmm 150-400 SEGMENT 51 % H 13.9~49.5(>1Y-4Y) SEGMENT 51 % H 13.9~49.5(>1Y-4Y) LYMPHOCYTE 43 % L 44.7~81.6(>1Y-4 Y) LYMPHOCYTE 43 % L 44.7~81.6(>1Y-4 Y) MONOCYTE 5 % 1.3~ 7.2(>1Y-4Y ) MONOCYTE 5 % 1.3~ 7.2(>1Y-4Y ) EOSINOPHIL 1 % 0.0~ 4.3(>1Y-4Y ) EOSINOPHIL 1 % 0.0~ 4.3(>1Y-4Y ) BCS 2006/08/06 1915 CRP 22.02 mg/L H < 5 CRP 22.02 mg/L H < 5

19. Case 1 Urine Analysis 2006/08/06 2126 COLOR YELLOW YELLOW COLOR YELLOW YELLOW TURBIDITY CLEAR CLEAR TURBIDITY CLEAR CLEAR SP.GRAVITY 1.010 1.005-1.030 SP.GRAVITY 1.010 1.005-1.030 PH 6.0 4.5 - 8.0 PH 6.0 4.5 - 8.0 LEUKOCYTE NEGATIVE NEGATIVE LEUKOCYTE NEGATIVE NEGATIVE NITRITE NEGATIVE NEGATIVE NITRITE NEGATIVE NEGATIVE PROTEIN NEGATIVE mg/dL NEGATIVE PROTEIN NEGATIVE mg/dL NEGATIVE GLUCOSE NEGATIVE g/dL NEGATIVE GLUCOSE NEGATIVE g/dL NEGATIVE KETONE 2+ NEGATIVE KETONE 2+ NEGATIVE UBG 0.1 EU/dL 0.1 - 1.0 EU/DL UBG 0.1 EU/dL 0.1 - 1.0 EU/DL BILIRUBIN NEGATIVE NEGATIVE BILIRUBIN NEGATIVE NEGATIVE BLOOD NEGATIVE NEGATIVE BLOOD NEGATIVE NEGATIVE RBC 0 HPF 0-2/HPF RBC 0 HPF 0-2/HPF WBC 0 HPF 0-5/HPF WBC 0 HPF 0-5/HPF SQUAMUS 0 CELL/HPF 0-5/HPF SQUAMUS 0 CELL/HPF 0-5/HPF

20. Case 1 Case 1 8/6 00:25 bedside echo: Target sign! Target sign! Intussusception is highly suspected!!  arrange fluoroscopic reduction

21. Fluoroscopic reduction of intussusception Small gas 明 顯比之前增多 原本脹大的 small bowel gas density Air enema 打進的 air density

25. 1. 原本的 mass 不見了 2.Small bowel gas 增多 Successful reduction!!!

26. Case 1 8/7 00:37 fluoroscopic reduction of intussusception 8/7 00:37 fluoroscopic reduction of intussusception A soft tissue density at the distal ascending colon, C/W A soft tissue density at the distal ascending colon, C/W intussusception. intussusception. Subsequent air enema via pressure-monitored device was Subsequent air enema via pressure-monitored device was performed. Soft tissue was advanced from the A-colon to the performed. Soft tissue was advanced from the A-colon to the ileocecal region then arresteed even with high pressure up to ileocecal region then arresteed even with high pressure up to 150 mmHg. 150 mmHg. No free influx of air into the distal ileum, suggestive of tight No free influx of air into the distal ileum, suggestive of tight intussusception. intussusception. Due to fear of colon rupture, the procedure was terminated with the parents' consent. Due to fear of colon rupture, the procedure was terminated with the parents' consent. IMP: C/W Intussusception, ileocolic type, with air reduction in vain. IMP: C/W Intussusception, ileocolic type, with air reduction in vain.

27. Case 1 8/7 02:10 consult GS 8/7 02:10 consult GS Failure of air reduction for intussusception. Surgical intervention is indicated, but no available pediatric surgeon right now. Failure of air reduction for intussusception. Surgical intervention is indicated, but no available pediatric surgeon right now. 8/7 02:50 transfer to 林口長庚 for op 8/7 02:50 transfer to 林口長庚 for op Surgeon consultation: suggest another try of air reduction. Surgeon consultation: suggest another try of air reduction. no irritable cry or bedside echo target sign on 8/7 morning! => follow clinical course and arrange abdominal echo

28. Case 1 2006/08/07 abdominal sonography 2006/08/07 abdominal sonography Impression: Bowel edema Impression: Bowel edema => no target sign noted !! => no target sign noted !! no intussusception now no intussusception now 8/7 15:44 admission to ward, keep NPO 8/7 15:44 admission to ward, keep NPO 8/8 try soft diet 8/8 try soft diet 8/10 MBD, lactobacillus 1# bid po * 5days 8/10 MBD, lactobacillus 1# bid po * 5days

29. Case 2 謝 X 君 7170540 謝 X 君 7170540 Age: 4 months old, gender: male Age: 4 months old, gender: male BW:7.6kg BW:7.6kg 基隆長庚 就診時間 : 2006/03/14 15:26 基隆長庚 就診時間 : 2006/03/14 15:26 vital signs: TPR: 36.4/170/25 vital signs: TPR: 36.4/170/25 BP: 120/70 mmHg BP: 120/70 mmHg GCS: E4V5M6, SaO2:98% GCS: E4V5M6, SaO2:98%

30. Case 2 Chief complain: Chief complain: Billious vomiting noted since 2 days ago for 5-6 times. Billious vomiting noted since 2 days ago for 5-6 times. Present illness: Present illness: Transfer from LMD Transfer from LMD Postprandial vomiting, last vomiting:1.5 hrs ago Postprandial vomiting, last vomiting:1.5 hrs ago no stool for 2 days, no bloody stool or currant jelly stool no stool for 2 days, no bloody stool or currant jelly stool No fever, cough or rhinorrhea No fever, cough or rhinorrhea Irritable crying, decreased activity Irritable crying, decreased activity Formula intake: 150-180cc  <100cc Formula intake: 150-180cc  <100cc Past history: Past history: No known drug allergies No known drug allergies No op or admission history No op or admission history vaccination: on schedule vaccination: on schedule

31. Case 2 Physical examination Physical examination HEENT: no active lesion HEENT: no active lesion HEART: tachycardia without murmur HEART: tachycardia without murmur CHEST :clear BS CHEST :clear BS ABD : soft and mild distended ABD : soft and mild distended bowel sound hyperactive bowel sound hyperactive EXT: freely movable EXT: freely movable Impression: Impression: Billious vomiting, cause? Billious vomiting, cause? R/O AGE R/O AGE R/O intussusception R/O intussusception

32. Case 2 Order 3/14 15:36 CXR CXR CBC,D/C, BUN, CRP, NA, K, Sugar CBC,D/C, BUN, CRP, NA, K, Sugar D5.225S run 50 cc/hr D5.225S run 50 cc/hr

33. Case 2 Case 2 3/14 15:46 arrange fluoroscopic reduction

34. Fluoroscopic reduction

36. unsuccessful reduction !

37. Case 2 3/14 Fluoroscopic reduction of intussusception 3/14 Fluoroscopic reduction of intussusception A soft tissue density at hepatic flexture, c/w intussusception. A soft tissue density at hepatic flexture, c/w intussusception. Subsequent air enema via pressure-monitored device was Subsequent air enema via pressure-monitored device was performed. performed. However, the free reflux of air can not be passed into A-colon despite of at least four attempts. However, the free reflux of air can not be passed into A-colon despite of at least four attempts. It indicates the unsuccessful reduction. It indicates the unsuccessful reduction.Impression: Intussusception, with unsuccessful reduction. Intussusception, with unsuccessful reduction.

38. Case 2 3/14 17:00 3/14 17:00 consult GS: transfer to 林口 for op consult GS: transfer to 林口 for op Cefazolin 25mg iv stat Cefazolin 25mg iv stat Gentamicin 15mg iv stat Gentamicin 15mg iv stat 3/14 18:26 轉入林口長庚 3/14 18:26 轉入林口長庚 3/14 Order 18:59 3/14 Order 18:59 admission admission NPO with NG decompression(Fr10) NPO with NG decompression(Fr10) IVF D51/4S run 60cc/hr IVF D51/4S run 60cc/hr Anegyn 70mg iv stat Anegyn 70mg iv stat Sign op permit, op on call Sign op permit, op on call

39. Case 2 3/14 19:48 op (4hrs 22mins later) 3/14 19:48 op (4hrs 22mins later) OP Finding: OP Finding: bloody ascites, severe small bowel dilataion and a sausage shape mass within the abdominal cavity, an ileo-colic type intussusception with gangrene at right upper abdomen, segmental rsection and anastomosis with two layers sutures performed. bloody ascites, severe small bowel dilataion and a sausage shape mass within the abdominal cavity, an ileo-colic type intussusception with gangrene at right upper abdomen, segmental rsection and anastomosis with two layers sutures performed. Operative method: Operative method: Milking reduction of intussusception with bowel resection and anastomosis Milking reduction of intussusception with bowel resection and anastomosis

40. Case 2 3/14 21:44 transfer to ICU 3/14 21:44 transfer to ICU keep GM + Metronidazole keep GM + Metronidazole fever noted on 3/15 early morning fever noted on 3/15 early morning NG with decompression NG with decompression 3/19 try sip water then on diet as tolerate 3/19 try sip water then on diet as tolerate 3/20 DC GM and metronidazole 3/20 DC GM and metronidazole 3/22 MBD 3/22 MBD

41. Discussion 1. What makes you suspect intussusception? 2. How do we comfirm intussusception? Management? 3. 什麼樣的病人不能做 fluoroscopic reduction? 病人有血便可不可以做 ? 4. 什麼樣的病人要直接 op? 5. 需不需要使用抗生素 ? 6. Recurrence 時處理有何不同 ?

42. Intussusception Greenfield's Surgery: SCIENTIFIC PRINCIPLES AND PRACTICE, 4th Edition

43. Intussusception the most common abdominal emergency in early childhood, particularly in children the most common abdominal emergency in early childhood, particularly in children younger than two years of age (80%). the majority of cases in children are idiopathic. A lead point is recognized more commonly in children older than five years. A lead point is recognized more commonly in children older than five years. Intussusception occurs (ileo-ileo-colic, jejuno-jejunal, jejuno-ileal, or colo-colic intussusception also have been described) Intussusception occurs most often near the ileocecal junction. (ileo-ileo-colic, jejuno-jejunal, jejuno-ileal, or colo-colic intussusception also have been described) Up to date~ intussusception in children

44. Intussusception symptoms and signs Sudden onset of intermittent, severe, crampy, progressive abdominal pain. Sudden onset of intermittent, severe, crampy, progressive abdominal pain. usually occur at 15 to 20 minute intervals. usually occur at 15 to 20 minute intervals. become more frequent and more severe over time. become more frequent and more severe over time. accompanied by inconsolable crying and drawing up of the legs toward the abdomen. accompanied by inconsolable crying and drawing up of the legs toward the abdomen. between the painful episodes, the child may behave relatively normally and be free of pain. between the painful episodes, the child may behave relatively normally and be free of pain. Initial emesis is non-bilious(6-12hrs), but it may become bilious as the obstruction progresses. Initial emesis is non-bilious(6-12hrs), but it may become bilious as the obstruction progresses. Up to date~ intussusception in children

45. Detect Abdominal pain in patient < 2yrs old “ crying out ” “ crying out ” Inconsolable Inconsolable moaning with lethargy moaning with lethargy constantly drawing the legs up with sudden movements or jerks constantly drawing the legs up with sudden movements or jerks irritability accentuated with attempts at comforting or rocking irritability accentuated with attempts at comforting or rocking

46. Currant Jelly Stool: Currant Jelly Stool: 紅醋栗 果醬便 mixture of blood and mucous Late manifestation of intussusception !!

47. Intussusception symptoms and signs Journal of gastroenterology and hepatology (2006) 21, 842-846

48. Intussusception symptoms and signs the classically described triad (pain, a palpable sausage shaped abdominal mass, currant-jelly stool) is seen in one-third of patients at the time of presentation. the classically described triad (pain, a palpable sausage shaped abdominal mass, currant-jelly stool) is seen in one-third of patients at the time of presentation. Clinical diagnosis of intussusception by signs and symptoms alone has been shown to be incorrect in one-half of patients presenting at an emergency department. (The pediatric infectious disease journal. Vol.25, NO1, Jan. 2006 review article) Clinical diagnosis of intussusception by signs and symptoms alone has been shown to be incorrect in one-half of patients presenting at an emergency department. (The pediatric infectious disease journal. Vol.25, NO1, Jan. 2006 review article)

49. Abdominal pain evaluation What ’ s the best tool ??? What ’ s the best tool ??? Abdominal sonography Abdominal sonography CT CT Intestine obstruction on films: a barium enema examination helps to differentiate between Hirschsprung disease, malrotation, and colonic stenosis, and separates lower large bowel obstruction from upper small bowel obstruction Intestine obstruction on films: a barium enema examination helps to differentiate between Hirschsprung disease, malrotation, and colonic stenosis, and separates lower large bowel obstruction from upper small bowel obstruction

50. Sonography vs CT in intussusception Echo: Echo: sensitivity and specificity approach 100 % in the hands of an experienced ultrasonographer. sensitivity and specificity approach 100 % in the hands of an experienced ultrasonographer. classic image "bull's eye" lesion representing layers of the intestine within the intestine classic image "bull's eye" lesion representing layers of the intestine within the intestine CT: CT: can be recognized on CT, which also can sometimes identify the cause. can be recognized on CT, which also can sometimes identify the cause. CT cannot be used to reduce the intussusception and can be time-consuming in children. Up to date~ intussusception in children

51. Evaluation and Management Fluoroscopic reduction The standard procedure for diagnosis and treatment of intussusception is a contrast (air favored) enema. The standard procedure for diagnosis and treatment of intussusception is a contrast (air favored) enema. Successful air enema reduction: Successful air enema reduction: 1. reflux of air into the terminal ileum 2. disappearance of the mass at the ileocecal valve Success rate: 75-90% of ileo-colic intussusception. Success rate: 75-90% of ileo-colic intussusception. main risk of hydrostatic or pneumatic reduction is perforation (<1%). main risk of hydrostatic or pneumatic reduction is perforation (<1%). Up to date~ intussusception in children

52. Fluoroscopic reduction Greatest risk of perforation in: Greatest risk of perforation in: 1. infants younger than six months of age who have had symptoms for three days or longer. 2. patients with evidence of small bowel obstruction Nonoperative reduction should not be attempted in patients with prolonged symptoms or any signs of peritoneal irritation or free peritoneal air. 病人血便可以做 air enema 嗎 ?? 病人血便可以做 air enema 嗎 ?? clinical experience by radiologist: 看病人是否 toxic!! clinical experience by radiologist: 看病人是否 toxic!! 不做 reduction 也可以幫助 diagnosis. 不做 reduction 也可以幫助 diagnosis. Up to date~ intussusception in children

53. Fluoroscopic reduction The pediatric surgeon should be consulted before diagnostic procedures, so that prompt surgery can be done if reduction is unsuccessful or if there is a complication The pediatric surgeon should be consulted before diagnostic procedures, so that prompt surgery can be done if reduction is unsuccessful or if there is a complication Perforation: Perforation: 1. Emergent operation. 2. needle decompression of the abdomen may be necessary if the excess air in the peritoneal cavity compromises the patient's respiratory status. Up to date~ intussusception in children

54. Fluoroscopic reduction Decreased success rate: Decreased success rate: infants younger than one year of age (particularly younger than three months) infants younger than one year of age (particularly younger than three months) older than five years of age older than five years of age when plain films show signs of intestinal obstruction when plain films show signs of intestinal obstruction lleo-ileo-colic intussusception lleo-ileo-colic intussusception Controversial: symptoms present for longer than 48 hours Controversial: symptoms present for longer than 48 hours Up to date~ intussusception in children

55. Fluoroscopic reduction Observation policy differed between countries and settings, with a minimum observation period of 12-36 hrs after conservative treatment. (The pediatric infectious disease journal. Vol.25, NO1, Jan. 2006 review article) Observation policy differed between countries and settings, with a minimum observation period of 12-36 hrs after conservative treatment. (The pediatric infectious disease journal. Vol.25, NO1, Jan. 2006 review article) Recurrence after successful nonoperative reduction is approximately 10%. Recurrence after successful nonoperative reduction is approximately 10%. Recurrence is not necessarily an indication for surgery.  處理流程跟第一次發作一樣 Recurrence is not necessarily an indication for surgery.  處理流程跟第一次發作一樣

56. Intussusception When for operation? When for operation? 1. nonoperative reduction is incomplete 2. prolonged symptoms (how long? No conclusion) 3. signs of peritoneal irritation or free peritoneal air When should we use antibiotics ? When should we use antibiotics ?  Not regularly given.  Broad-spectrum intravenous antibiotics should be given before surgery.  Peritonitis, perforation (~ micromedex) Up to date~ intussusception in children

57. Key points Typical symptoms and signs may not be seen in intussusception patients. Typical symptoms and signs may not be seen in intussusception patients. Observation, repeated PE and explanation are important. Observation, repeated PE and explanation are important. Abdominal sonography can be helpful in ER for differential diagnosis!! Abdominal sonography can be helpful in ER for differential diagnosis!! Nonoperative reduction should not be attempted in patients with prolonged symptoms or any signs of peritoneal irritation or free peritoneal air. Well explain the possible complication before fluoroscopic reduction in a patient with bloody stool.

58. Thank your for your attention!!!