1. NYU Medical Grand Rounds Clinical Vignette Rennie Rhee MD, PGY-2 January 13, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. A 51-year-old man presents with bloody diarrhea for 6 months. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS The patient was in his usual state of health until 6 months prior to admission, when he began to experience fever and bloody diarrhea. He would experience 10-15 episodes of diarrhea per day with increasing amount of blood clots noted in his stool. At that time, the patient initially presented to the emergency room and an abdominal CT demonstrated pancolitis. The patient was given presumptive diagnosis of infectious enterocolitis and discharged home on antibiotics.

4. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Two weeks later, the patient presented in clinic reporting persistence of his diarrhea. Colonoscopy was performed showing patchy erythematous mucosa of the colon. Biopsy demonstrated a slight increase of lymphoplasmacytic infiltrate from terminal ileum to the sigmoid colon, but mature glands with little crypt distortion and mature globlet cells.

5. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Given the unclear etiology of his diarrhea, the patient was given a trial of loperamide, but without relief. He was later given a trial of mesalamine for possible ulcerative colitis, and this provided marked improvement. 5 days prior to admission, however, the patient experienced recurrence of his frequent episodes of bloody diarrhea, abdominal pain, and rectal burning.

6. Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Past Medical History None Past Surgical History None Family History Father: Myocardial infarction at age 68 Social History Smoker, 40 pack-years Denies alcohol use Denies illicit drug use

7. Outpatient Medications U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Mesalamine 800mg three times daily Allergies: Penicillin (anaphylaxis)

8. Physical Examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS General: Well-appearing middle-aged man, in no acute distress Vitals: T 102.8F, BP 118/69, HR 91, RR 16 O 2 saturation: 97% on room air Abdominal: Soft, distended, normal bowel sounds, left lower quadrant pain on light and deep palpation The remainder of the physical exam was normal.

9. Initial Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS CBC: Hemoglobin 11.2 g/dL, Hematocrit 34% The remainder was within normal limits Basic Metabolic Panel: Within normal limits Hepatic Panel: Within normal limits C-reactive protein: 94 mg/L (0.215 – 3.0 mg/L)

10. Imaging U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Abdomen and Pelvis CT: Colonic inflammatory changes involving mid transverse colon to rectum Interval decrease in rectosigmoid inflammation Abdominal lymph nodes measuring up to 1.3 cm in right lower quadrant, most likely reactive Dilated appendix

11. Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Acute Exacerbation of Ulcerative Colitis

12. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Hospital Course The patient was started on prednisone and his mesalamine dose was increased. Mesalamine enemas were also initiated. Ciprofloxacin and metronidazole were empirically started due to concern for acute appendicitis. General Surgery recommended no surgical intervention.

13. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS During his hospitalization, the colonoscopy was repeated due to the original atypical biopsy results. New biopsies revealed chronic active colitis with crypt distortion, cryptitis, and crypt abscesses. The patient’s symptoms slowly improved and he was discharged in stable condition.

14. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Final Diagnosis Ulcerative Colitis