Case Presentation

1
Case Presentation

• Acute Diarrhoea

2
Mr AB

• 24 yo man lives interstate
• Presents with 3 days diarrhoea and 4 days
  abdominal pain and feeling generally unwell.
• 12-15 episodes of diarrhoea a day
• normal colour
• not watery but loose
• no blood or mucous
• Generalised non-specific crampy abdo pain, right
  worse than left, radiating to right back.
• worst pain ever experienced like stomach in a
  vice
• No vomiting, no fevers/sweats/rigors.
• Loss of appetite.

3
Past Medical History

• Gastroenteritis one year ago 24 hr bug
• Gastritis 18yo took Somac for a while

Medications

• No medications or allergies

Family History

• Parents and sister (25) well

Socially

• No infectious contacts,
• Just quit smoking 3 pk/wk, w/e ETOH binges
• Ate a dodgy chicken schnitzel on Friday at
  shopping centre

4
Examination

• HR 100, BP 100/70, T 364, RR18, Sats 100RA
• Looks unwell but not distressed or haemodyn.
  compromised.
• Soft abdo
• Right sided and
  bilateral IF
• tenderness
• No renal angle
  tenderness
• Mild RIF rebound
• No organomegaly
• BS increased

5
Examination II

• Stong Pulses, Dual Heart Sounds, no murmurs
• Chest Clear
• MMM, normal turgor, warm to touch, appears well
  perfused, thirsty
• FWT NAD
• BSL 4.6mmol

6
FBE
7
Other Bloods
8
Abdo XR
9
Questions

• Any other questions or examination points?
• DDx?
• Plan?

10
Progress

• Analgesia
• Pain well treated though not completely relived
  by Panadol and Buscopan
• IV Fluids
• HR 75, BP 120/80, T 373
• Admit Surg Single Room
• Observe ?appendicitis DDx gastroenteritis
• Faecal Spec for MCS collected in ED
• Loose brown sample, occasional WCC, RBC
• Overall feeling much better on PM WR.

11
21/7/2006 AM WR

• Little change
• few bouts of diarrhoea overnight
• crampy abdo pain persists on right side though
  not guarding as was yesterday
• still no temperature above 373
• feels hungry
• Dilemma
• definitive diagnosis of appendicitis can really
  only be made on laparoscopy
• What to do now?

12
Repeat Bloods
13
Repeat Bloods
14
CT Abdo/Pelvis
15
CT Abdo/Pelvis
16
CT Abdo/Pelvis
17
CT Abdo/Pelvis
18
CT Abdo/Pelvis
19
CT Abdo/Pelvis
20
CT Abdo/Pelvis
21
CT Abdo/Pelvis
22
CT Abdo/Pelvis
23
CT Abdo/Pelvis
24
CT Abdo/Pelvis
25
CT Abdo/Pelvis
26
CT Abdo/Pelvis
27
CT Abdo/Pelvis
28
CT Abdo/Pelvis
29
CT Abdo/Pelvis
30
CT Abdo/Pelvis
31
CT Abdo/Pelvis
32
CT Abdo/Pelvis
33
CT Abdo/Pelvis
34
CT Abdo/Pelvis
35
CT Abdo/Pelvis
36
CT Abdo/Pelvis
37
CT Abdo/Pelvis
38
CT Abdo/Pelvis
39
CT Abdo/Pelvis
40
CT Abdo/Pelvis
41
CT Abdo/Pelvis
42
CT Abdo/Pelvis
43
CT Abdo/Pelvis
44
CT Abdo/Pelvis
45
CT Abdo/Pelvis
46
CT Abdo/Pelvis
47
CT Abdo/Pelvis
48
CT Abdo/Pelvis
49
CT Abdo/Pelvis
50
CT Abdo/Pelvis
51
CT Abdo/Pelvis
52
CT Abdo/Pelvis
53
CT Abdo/Pelvis
54
CT Abdo/Pelvis
55
CT Abdo/Pelvis
56
CT Abdo/Pelvis
57
CT Abdo/Pelvis
58
CT Abdo/Pelvis
59
CT Abdo/Pelvis
60
CT Abdo/Pelvis
61
CT Abdo/Pelvis
62
CT Report

• Severe right sided colitis extending from caecum
  to hepatic flexure.
• No terminal ileitis.
• No skip lesions.
• Suggest biopsy!!!!

AXR Report

• No soft tissue definition.
• Some loss of definition within the right
  sacroiliac joint.
• ? inflammatory arthropathy.

63
Further History

• Frequently gets sore knees and shoulders from
  time to time.
• blames it on football
• Back pain occasionally
• when standing for long periods
• doesnt know if always worse on right
• No chronic diarrhoea.
• No history of red eye, skin complaints, non-axial
  joint pain, redness or stiffness, no mouth
  ulcers, no other extra-intestinal manifestations
  of IBD.

64
Progress

• Diarrhoea and pain settled and patient tolerating
  FWD at day two admission.
• Back pain occasional and mild.
• Gastro Med Review
• no active treatment required at this stage if
  symptoms improving
• requires gastro and rheum f/u
• otherwise can go home
• will need colonoscopy in 4-6 weeks
• GP in Newcastle was contacted.
• D/C three days after admission.