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An 80YearOld Man with Abdominal Pain and Weight Loss

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Comfortable and alert. Could answer simple questions, but memory poor. BP: 130/80. HR: 70 bpm ... prostate hard? Does he have prostatitis or prostate cancer? ... – PowerPoint PPT presentation

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Title: An 80YearOld Man with Abdominal Pain and Weight Loss

1
An 80-Year-Old Man with Abdominal Pain and Weight
Loss
Eugene G. Martin, Ph.D. Associate Professor of
Pathology Laboratory Medicine

Based upon LABORATORY MEDICINE CASEBOOK. An
introduction to clinical reasoning
Jana Raskova, MD Professor of Pathology
Laboratory MedicineStephen Shea, MD
Professor of Pathology Laboratory
MedicineFrederick Skvara, MD Associate
Professor of Pathology Laboratory MedicineNagy
Mikhail, MD Assistant Professor of Pathology
Laboratory MedicineUMDNJ-Robert Wood Johnson
Medical SchoolPiscataway, NJ

2
History and Presentation

80 year old male admitted to the hospital with
complains of lower abdominal pain.
Lost 16 lbs. in recent months
No other complaints or significant medical or
surgical history
Physical Exam
Comfortable and alert
Could answer simple questions, but memory poor
BP 130/80
HR 70 bpm
Afebrile
Chest exam unremarkable
Abdomen soft bowel sounds present. Tenderness
LLQ
Rectal exam enlarged, hard prostate
Stool negative for occult blood
A CT scan of the abdomen was performed

3
What questions need to be addressed?

Why does his belly hurt?
Why a recent sixteen pound weight loss?
Why is his prostate hard?
Does he have prostatitis or prostate cancer?
If a cancer is it primary or metastatic?
Why is his memory so poor?

4
HEMATOLOGY
5
Anemia Assessment

?Normocytic, normochromic anemia
Reticulocyte ?
Hemolytic disease
Acute blood loss
Reticulocyte normal
Malignancy
Myeloma
Chronic Disease
Macrocytosis is seen in
Megaloblastic anemias ?
vitamin B12 and folate deficiency
Some forms of chronic liver disease
Microcytosis and hypochromia
Iron deficiency anemia
Spherocytosis
Some forms of anemia of chronic disease

6
Anemia of Chronic Disease

Basic Mechanism
Reduction in life span of RBC from 120 days to
60-90 days
Enhanced phagocytic activity by macrophages
Hemolysis caused by bacterial toxins or tumor
secretions
Fever may damage the RBC cytoskeleton
Defect in iron transfer from stores in the bone
marrow to the plasma.
Impaired bone marrow response to the anemia
Normal response to decreased O2 carrying capacity
is to increase erythropoietin production in the
kidneys which stimulates RBC maturation in the
bone marrow and release into the circulation.
Laboratory Pattern in ACD
Serum iron ? (mean 30 µg/dl)
TIBC ? (mean 200 µg/dl)
Saturation ? (mean 10-25)
Ferritin Normal to ?.
A normal or raised ferritin EXCLUDES the
possibility of iron deficiency. However, ferritin
can be ? in infectious and malignant disease,
such as disseminated TB or Hodgkins and can be
markedly elevated in acute hepatitis due to the
release of liver iron stores.

The Anemia of Chronic disease (ACD) is usually
mild and asymptomatic.
Physical findings and symptoms are dependent upon
the underlying disease infectious, inflammatory,
or malignant.
Presentation - NON-SPECIFIC
Fatigue
Shortness of breath
Loss of appetite
Weight loss, or
Lightheadedness after mild activity.
Either normocytic or microcytic (Confusing
resembles iron deficiency anemia)
Mild to moderate anemia - rarely results in a Hgb
lt 8 gm/dl. Usually develops gradually and
stabilizes with a Hct between 25-40.

7
Anemia of Chronic Disease

Chronic Renal Disease
Uremia - moderate degrees of anemia
Vy. Frequent when BUN is gt 2x normal
Normochromic, normocytic
Burr cells common
Bone marrow normal cellularity
Marrow iron adequate
Failure of iron incorporation into RBCs
Platelet function abnormal

Anemia of Neoplasia
60-90 of patients with advanced cancer
Normocytic, normochromic
Normal platelet counts
Exceptions
Cytotoxic chemotherapeutic anemia is macrocytotic
Thrombocytopenia
Leukemia
Myelphthisic anemia
Other forms of ACD Infections, liver disease and
hypothyroidism

8
CHEMISTRY
9
Urinalysis
10
Additional Studies
Coagulation
Electrolytes
11
Usefulness of CO2

Patient High K, High Cl-, Very Low CO2
Electrolytes
Acidosis
High K
Low CO2
Alkalosis
Low Cl-
High CO2
Note the CO2 which is part of an electrolyte
panel is actually a measurement of the serum
bicarbonate (HCO3-).
In other words the CO2 on the Lytes Panel is the
same as the HCO3 on the ABGs
http//www.southalabama.edu/nursing/3472010120sp
04/AHN347AcidBase.pdf

12
Peripheral Blood Smear
Patient
Normal

Normochromic, normocytic anemia.
Red cell population is decreased in number
Cell size and shape normal
Platelets and neutrophils unremarkable
None of this information adds anything to the
automated hematology count shown earlier

13
CT Scans
Patient
Normal

Summary of findings
Left Kidney
Enlarged
Hydronephrotic
Staghorn calculus
Renal cortex markedly thinned
Right Kidney
Compensates for declining function left kidney

14
Differential of enlarged prostate

Bacterial Prostatitis
Symptoms
Fever
Chills
Dysuria painful urination
Tender prostate

Neoplasia
Non-tender, enlarged prostate
Prostatic acid phosphatase (PAP)
? in locally invasive or widely metastic
prostate carcinoma
Prostate Specific Antigen
? in proportion to volume of prostate tissue
May be elevated in normal prostatic tissue,
benign p. hyperplasia, cancer of the prostate,
chronic prostatis

15
PROSTATE NEEDLE BIOPSY

Irregular shaped alveoli throughout fibromuscular
stroma
Glands are lined by columnar epithelium with
round or oval nuclei, inconspicuous nucleoli
Infiltration of gland by numerous, small,
tightly-packed acini
Cells are cuboidal, nuceli enlarged, irregular
with irregular nucleoli
Dx Prostatic adenocarcinoma

NORMAL
PATIENT
16
DNA Ploidy/Cell Cycle Anal.

Normal
Diploid G1D DNA peak 92.8
Small G2D population (3.6) (normal lt 6)
Small S phase (3.6)

Normal

Patient
Diploid G1D DNA peak 77.6
G2D population is ? 7.4 (normal lt5)
S phase ? (15.8)
31 have aneuploid DNA content

Patient
17
Cell Cycle Analysis

DNA content X-axis
No. of cells of given staining intensity Y-axis
G1D - G0/G1 phase of the diploid population
G2D G0/G1 phase of the aneuploid population
S phase Synthetic phase with intermediate
DNA content

18
Whole Body Imaging 99mTc-diphosphate

Numerous abnormal foci or hot spots are present
in axial skeleton and appendicular skeleton
Hot spots represent areas of increased blood flow
or reactive bone formation
Destructive
Inflammatory
Arthritic lesions
SENSITIVE, BUT NOT SPECIFIC!!

19
Case Summary