A 29 yr old male

1

• A 29 yr old male
• Software engineer Doha
• Came to casualty on 15/07/08 with c/o
• abdominal pain 3 wks back
• loose stools 2wks
• fever started 5 days later

2
History of present illness

• Initially started as abdominal pain 3 wks back
• Cramping pain
• Diffuse all over abdomen but more on lower
  abdomen on left side
• Increased by intake of food , asso with a feeling
  to evacuate .
• Associated nausea vomitings
• Vomiting only for first 3 days
• undigested food particles

3

• Loose stools started 1 wk later
• Recurrent episodes of foul smelling watery
  stools, not blood stained.
• Initially started as 1-2 episodes /day
  progressively increased to 10 -15 /day
• Noticed blood in stools only since past 3 days.

4

• Fever started 5 days after the loose stools have
  begun
• Low grade
• Not associated with chills rigors
• No h/o headache
• h/o travel to bombay (16/06/08) (6 days prior)
• No h/o rhinitis, cough, dyspnea
• No h/o chest pain, palpitations, syncope
• No h/o loss of consciousness, focal neurological
  deficit, seizures

5

• No h/o joint pains
• No h/o burning micturition
• No h/o significant wt loss
• Not a known diabetic, hypertensive
• Past history no significant past history
• Personal history no h/o smoking, alcoholism

6
On examination

• No pallor , icterus, cyanosis, clubbing, pedal
  edema, no gen.lymphadenopathy
• Pulse 100/min , regular
• BP 110 / 70 mm Hg
• Temp 99.2 F
• RR 16 / min regular , abdomino-thoracic
• dehydrated

7
On examination

• CVS S1 S2 , no murmurs
• RS NVBS no added sounds
• GIT Oral cavity NAD
• P/A soft
• mild tenderness in lt iliac
  fossa
• no hepatosplenomegaly
• bowel sounds

8
On examination

• NS Conscious , coherent
• hmf normal
• no neck stiffness
• no cranial nerve palsies
• no sensory motor deficit
• no cerebellar signs
• DTR b/l normal
• plantar b/l flexor

9
Provisional diagnosis

• Acute bacterial dysentry
• Enteric fever
• Amoebic dysentry

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Investigations

• CBC raised WBC ( 19.5 )
• DC N 68.6
• L 7.65
• E 8.34
• Hb 14.5 g/dl
• platelets 395 K/uL

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investigations

• ESR 34 / mm 1 st hr
• RFT normal
• LFT Total protein 6.2
• S.Albumin 2.7
• S.Globulin 3.5
• S.Na 131.5 mmols/L
• S.K 3.6 mmols/L
• Urine routine normal

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investigations

• CXR PA view normal
• ECG normal
• Stool Routine , Blood C/S, Stool C/S,
• WIDAL results awaited

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treatment

• Inj.CIFRAN 200mg IV Stat OD
• Inj.METROGYL 500mg IV Stat TID
• Inj PANTOCID 40mg Stat BD
• Tab. REDOTRIL TID
• Tab. BIFILAC TID
• IV FLUIDS

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Investigations

• Stool for Ova Parasites No parasites seen
• Stool C/S no enteric pathogen isolated
• Blood C/S no growth
• USG Abdomen Pelvis multiple gall bladder
  polyp
• WIDAL - negative

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• Patient continued to have loose stools 8 10
  times / day
• Passage fresh blood at end of stools
• On ex vitals stable
• tenderness in lt. iliac fossa
• increased

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Investigations

• Mantoux negative

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• On repeated questioning ----
• Pt gave history of occasional lower gi bleed
  since last 1 year.
• Occupational history in detail was asked
• irregular working hours
• hectic schedules deadlines
• stress

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• Possibility of Acute colitis / Inflammatory
  bowel
• were considered

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CT ABDOMEN with CONTRAST

• diffuse increase in contrast enhancement of large
  bowel compared to small bowel
• Increased mucosal thickening with minimal
  pericolonic fat stranding multiple small ileo
  colonic nodes
• Normal abd aorta angiography.
• Above findings sugg of colitis .
• Suggest clinico pathological correlation

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• Gastro medicine consultation was asked for (
  17/07/08)
• Sigmoidoscopy (18/07/08) rectum showed loss of
  vascular pattern.
• Sigmoid colon showed multiple healed ulcers
  with psedopolyps.
• Impression Lt sided colitis.
• ? Crohns disease ?
  Ulcerative colitis
• Biopsy taken

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• Tab. MESAAL 2-2-2
• Tab FOLVITE 5mg 1-0-0
• To continue IV CIPLOX 200mg BD for 10 days.
• 2 ffp transfused
• Tab.Methyl prednisolone 32mg 1-0-0

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Sigmoidoscopy biopsy

• Mucosal biopsies of lt.colon, rectum
• Consistent with inflammatory bowel disease.
• indeterminate colitis.

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• Gastro medicine take over adviced on
• 29/07/08
• Endocrinology consultation for hyperglycemia.
• imp steroid induced hyperglycemia
• adviced diabetic diet lifestyle
  modification.

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FINAL DIAGNOSIS

• Inflammatory bowel disease

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Advice on discharge

• To review after 2 wks in gastromedicine
  endocrinology OPD with CBC, CRP, FBS, PPBS.
• DIET Recommendations
• diabetic diet
• lifestyle modification
• protein 60mg/day

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Discharge medication

• Tab.CIPLOX TZ 1-0-1 for 5 days
• Cap.BIFILAC TID for 1 month
• Tab.MESACOL 4OOmg 2-2-2 for 1 month
• Tab.FOLIC ACID 5mg OD for 1 month
• Tab.METHYL PREDNISOLONE 32mg OD
• Tab.NEXPRO 20mg OD for 1 month
• Steam inhalation SOS

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Clinical Ul.colitis Crohns
Gross blood in stool Yes Occasionally
Mucus Yes Occasionally
Systemic symptoms Occasionaally Frequently
Pain Occasionally Frequently
Abd.mass Rarely yes
Sig.perineal.ds No frequently
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Clinical Ul.colitis crohns
Fistulas No Yes
Small intestinal obs No Frequently
Colonic obs Rarely Frequently
Response to antibiotics No Yes
Recurrence after surgery No Yes
ANCA Frequently rarely
ASCA Rarely frequently
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Endoscopic features Ul.colits Crohns ds
Rectal sparing Rarely Frequently
Continous ds Yes Occasionally
Cobble stone pattern No Yes
Granuloma on biopsy No occasionally
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Radiographic Ul.colits Crohns ds
Small bowel significantly abn No Yes
Abn.terminal ileum Occasionally Yes
Segmental colitis No Yes
Asymmetric colitis No Yes
Stricture Occasionally frequently
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Treatment optionsDISTAL UC EXTENSIVE UC

• 5 ASA PR/PO
• Glucocorticoid rectal
• Glucocorticoid oral
• Glucocorticoid IV
• 6-Mercaptopurine/ Azathioprine
• IV Cyclosporine, Infliximab

• 5 ASA rectal/oral
• Glucocorticoid rectal
• Glucorticoid oral
• Glucocorticoid IV
• 6-Mercaptopurine/ Azathioprine
• IV Cyclosporine/ Infliximab

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Inflammatory CD Fisutlizing CD

• Sulfasalazine antibiotics
• Budesonide ( ileal r.colon)
• Prednisolone
• Glucocorticoid IV
• 6-Mercaptopurine/ Azathioprine
• Methotrexate
• Infliximab/ Adalimumab
• IV Cyclosporine/ Infliximab

• Antibiotics
• 6- Mercaptopurine/ Azathioprine
• Methotrexate
• Infliximab/ Adalimumab
• IV Cyclosporine / tacrolimus
• TPN

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Treatment

• Adalimumab recombinant human monoclonal IgG1
  Antibody for CD
• Certolizumab Pegol pegylated form of anti- TNF
  antibody active inflammatory CD.

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• Thank You