Hematochezia University of Pennsylvania

Department of Surgery

HPI ƒ Julie K. is a 32-year-old lady who presents to

her primary h i care physician h i i with ith a four f week k history of passing bloody bowel movements.

History What other points of the history do you want to know?

History Consider the following: • Characterization of

Symptoms • Temporal sequence • Alleviating / Exacerbating factors:

• Associated Signs & • • • • •

Symptoms Pertinent PMH ROS MEDS Relevant Family Hx Hx. Relevant Social Hx.

History Julie K. History, K ƒ Characterization of Symptoms and Temporal Sequence of Events – Patient noticed bright red blood in her stool b i i 4 weeks beginning k ago, sometimes ti mixed i d with ith mucous. Her bowel movements have been loose but formed. – She has approximately 3 bowel movements daily and often feels an urgent need to d f defecate. – She has also noticed intermittent crampy abdominal pain and a decrease in appetite over the past month.

History Julie K. History, K ƒ Alleviating/Precipitating g p g Factors – Abdominal pain often worsens with eating – Nothing g alleviates symptoms y p

ƒ Associated Symptoms – No Nausea or Vomiting – Decreased Appetite – Weight loss of about 10 lbs over past month

History Julie K. History, K ƒ Has this happened before? – She has experienced abdominal pain and bloody diarrhea twice in the past year but never lasting more than 2-3 days

ƒ Sick Contacts and Travel History – No known sick contacts – No N recentt ttravell outt off the th country t

Additional History, History Julie K. K ƒ PMH – None

ƒ PSH – Appendectomy at age 9

ƒ Meds: – None N

Additional History, History Julie K. K ƒ Family History – Several family members have had intestinal problems” problems “intestinal

ƒ Social History – Smoked S k d ½ pack k per d day ffor 10 years until 2 years ago, social ETOH consumption no other drug use consumption, – Sexually active in monogamous relationship

What is you Differential Di Diagnosis? i ?

Differential Diagnosis Based on History and Presentation ƒ Inflammatory Bowel Disease – Crohn’s Disease – Ulcerative Colitis ƒ Infectious Colitis ƒ Parasites: Strongyloidiasis Strongyloidiasis, Amebiasis ƒ Rectal or Colon Cancer or Lymphoma ƒ Diverticulitis ƒ Radiation Enteritis ƒ Gastroenteritis G t t iti

Ph sical Examination Physical E amination

Wh t specifically What ifi ll would ld you look l k for? f ?

Physical Examination Examination, J.K. JK ƒ Vital Signs: T = 37.3, P = 86, BP = 110/76, RR = 14

ƒ Appearance: thin, pale, but in no acute distress ƒ HEENT: Sclera anicteric, anicteric mucous membranes pink and moist ƒ Heart: RRR ƒ Lungs: mild rales at bases ƒ Abdomen: normoactive BS,, non-distended,, mildly tender throughout, no guarding or rebound tenderness ƒ Rectal: stool in vault mixed with bright red blood blood, no masses, no external anal lesions

Differential Diagnosis Would you like to update your differential?

Laboratory What would y you obtain?

L bR Lab Results lt 10 9 10.9 6.7

225

138

108

12

32.3

98 3.7

MCV = 82%

ƒ ƒ ƒ ƒ

LFTs WNL PT/PTT WNL Stool O&P negative C. difficile toxin negative

24 0 24.0

07 0.7

Laboratory ResultsDiscussion ƒ Normal WBC – infection less likely y ƒ Mild Anemia – likely from GI bleeding with chronic blood loss given low MCV ƒ Electrolytes - Normal ƒ C. C difficle diffi l toxin t i negative ti - sensitivity iti it iis 80 8099% based on assay with specificity of 99% making infection with ith C C. difficile highly highl unlikely

What are the Next Steps in Diagnosis and Management?

Further Diagnosis and Management • Interventions? • Imaging? • Endoscopy?

Abdominal X-Ray X Ra

X-ray interpretation • Normal abdominal film • No colonic dilatation • No signs of small bowel obstruction or ileus

Colonoscopy What would you expect to see?

Colonoscopy

Colonoscopy findings ƒ Colitis • • •

Friable, Ulcerated Mucosa Mucosal Edema and Erythema Hemorrhagic g

Colonoscopy ƒ Continuous inflammation of colonic mucous involving rectum and extending to the splenic flexure and into the early transverse colon ƒ Mucosa is erythematous erythematous, edematous edematous, and friable ƒ Pseudopolyps – inflammatory, inflammatory nonnon neoplastic mucosal projection ƒ Mucosal Biopsy demonstrates distortion of architecture with crypt branching, crypt g inflammatory y cells,, abscess containing ulceration; no granulomas

Diagnosis Ulcerative Colitis

What next?

Medical Management for Mild-to-Moderate Ulcerative Colitis ƒ 5-ASA agents – oral and rectal preparations

ƒ Oral Corticosteroids ƒ 6-MP/Azathioprine

Medical Management Julie K K. ƒ Julie K K. is started on Sulfasalazine 1g TID and also given a course of steroids ƒ Her symptoms improve dramatically over the next few days ƒ She Sh maintains i t i S Sulfasalazine lf l i th therapy ffor disease control despite minimal symptoms

Julie K K. returns ƒ Julie K. K now presents to the emergency department 3 weeks after completing the steroid taper taper. She began having crampy abdominal pain and bloody diarrhea 2 weeks ago increasing in severity over the past 5 days.

History, Julie K.

ƒ Characterization of Symptoms and Temporal Sequence of Events – Abdominal pain began gradually 2 weeks ago, was intermittent and crampy, but now worsening in severity and constant – Diarrhea also began 2 weeks ago. It was watery and mixed with bright red blood. Over th pastt 5 days the d patient ti t has h noted t d more blood bl d iin the toilet bowl. – She has been having g >10 Bowel movements daily – Today diarrhea is less than it has been the day before

History Julie K. History, K ƒ Alleviating/Precipitating Factors – She attempted to take over-the-counter antidiarrheal agents without relief – Patient P ti t feels f l worse with ith eating; ti she h h has avoided oral intake for the past week

ƒ Associated Symptoms – Subjective fevers and chills – Dizziness, Dizziness particularly on standing – Nausea, but no vomiting – No joint pain, pain no visual changes or eye pain

Physical Examination, Julie K. ƒ V.S:. T=38.7°C, BP=104/60 (seated), 90/50 (standing), HR=102 (seated), 116 (standing) ƒ General: thin, uncomfortable ƒ HEENT: sclera anicteric, mucous membranes dry, y no oral lesions ƒ Cardiovascular: tachycardic, normal S1 S2, S1, S2 grade II/VI systolic flow murmur

Physical Exam ƒ Lungs: Clear to Auscultation Bilaterally ƒ Abdominal Exam: Hypoactive BS, mildlyy distended, soft, diffuselyy tender but without rebound or guarding ƒ Rectal: no external anal lesions lesions, heme + stools ƒ Extremities:trace pedal edema

Diff Differential ti l Diagnosis Di i Would y you like to update p your y differential?

Laboratory What would you obtain?

Lab Results 8.9 300 28

ƒ ƒ ƒ ƒ

PMN’s =80% MCV = 80.1 LFTs WNL PT/PTT normal

ƒ ƒ ƒ ƒ

140

111

37

2.9

18

1.3

VBG: 7.35/35/40 AG= 10 Lactate: 1 1.1 1 Cultures and Stool Studies pending

Laboratory ResultsDiscussion ƒ Leukocytosis y – consistent with inflammation, could indicate infection ƒ Anemia – indicative of blood loss, likely acute on chronic blood loss given low MCV ƒ Mild Non-anion gap Metabolic Acidosis with appropriate respiratory compensation – seen in the context of diarrhea ƒ Hypokalemia – GI losses and volume depletion

Interventions at this point?

Consider the following I Immediate di t Interventions I t ti ƒ Admit to Hospital ƒ NPO ƒ Fluid Resuscitation with Isotonic Crystalloid • (NS LR (NS, LR, or Plasmalyte) ƒ Correct Electrolyte Abnormalities ƒ Stop St any narcotic, ti antidiarrheal, tidi h l or anticholinergic agents ƒ Begin IV Corticosteroids

Studies Do you want any further studies?

Abdominal X-Ray X Ray

Abdominal X-ray Discussion ƒ Dilated Dil t d C Colon l g ƒ Toxic Megacolon – Dilation of Transverse or Ascending Colon >6cm – No small bowel pathology

Colonoscopy py - Discussion ƒ Generally avoided during fulminant presentations of colitis ƒ Mayy be used cautiouslyy to determine presence of ischemic or pseudomembranous colitis ƒ Minimize insufflation used ƒ Should not be performed when there is colonic dilation and is contraindicated for cases of toxic megacolon

Abdominal CT (not necessary)

Abdominal CT - Interpretation ƒ Severe Colitis – Diffuse Colonic Wall Thickening with S b Submucosal l Ed Edema – Pericolic Stranding – Ascites

Medical Management of Severe Ulcerative Colitis ƒ Cyclosporine – Calcineurin inhibitor – Administer 2 2-4mg/kg/day 4mg/kg/day as continuous IV infusion if patient not responding to IV corticosteroids

ƒ Infliximab – Monoclonal antibody to TNFα – Administered as IV infusion

Hospital Course ƒ Symptoms do not improve on steroids and cyclosporine ƒ She continues to experience bloody diarrhea and worsening abdominal pain.

Final Diagnosis Ulcerative Colitis complicated by Fulminant Colitis with Toxic Megacolon

What next?

Management ƒ Continue Supportive pp Therapy py ƒ Medical Management – Broad spectrum antibiotics – will treat any infectious component and also offer coverage should p perforation occur – Continue IV corticosteroids

ƒ Bowel Decompression: NG tube ƒ Prepare for Surgery

Indications for Surgery ƒ ƒ ƒ ƒ ƒ

Perforation Uncontrolled Bleeding Progressive Dilation Worsening Symptoms Failure to Improve with Medical Management within 24 hours * Delay in surgical intervention leading to emergent surgery is associated with increased morbidity and mortality.

Surgical g Options p ƒ Subtotal Colectomy y and End Ileostomy (leaving rectal stump) ƒ Total Proctocolectomy with Ileal P Pouch–Anal h A lA Anastomosis t i (IPAA)

Subtotal Colectomy y

ƒ ƒ ƒ ƒ

Remove diseased colon Create ileostomy Allow toxic state to resolve Restorative proctocolectomy with ileal pouch–anal anastomosis (IPAA) at a later date

Discussion ƒ Serious Complications of fulminant presentations of Ulcerative Colitis include: – Massive Hemorrhage – Perforation – Toxic T i Megacolon M l ƒ Toxic Megacolon is defined as colonic distension >6cm 6c in the t e presence p ese ce o of a an act active e inflammatory a ato y process. ƒ Though most commonly associated with IBD, toxic megacolon may also complicate infectious colitis including Pseudomembranous colitis.

Discussion Diagnosis – There may be a history of Ulcerative Colitis, but approximately 10% of patients will present initially with fulminant colitis. – Historyy usually y includes cramping p g abdominal pain, increased bowel movements, and stool mixed with blood and d mucous. – There is often leukocytosis, anemia, and electrolyte disturbances disturbances.

Discussion Diagnosis – If toxic megacolon occurs, dilated colon will be visible on abdominal x-ray y and CT. CT is a good non-invasive modality for identifying subclinical complications of fulminant colitis such as perforations and abscesses. – Colonoscopy should be used with care when disease is active and is contraindicated if colon is dilated or patient has fulminant colitis

Discussion Management g – Non-surgical management includes aggressive fluid resuscitation, correction of electrolyte abnormalities, b liti administration d i i t ti off b broad d spectrum t antibiotics, and in the case of IBD (ulcerative colitis or Crohn’s disease), ), administration of corticosteroids – Additional medical management may include i immune modulator d l therapy h with i h cyclosporine l i or infliximab

Discussion Management – Surgery S is i iindicated di t d when h signs i and d symptoms t fail to improve with medical management or worsen – Emergent Surgery is also warranted in the setting of perforation, hemorrhage, progressive dil ti or toxic dilation t i megacolon. l – Surgical Management: subtotal colectomy with end ileostomy for emergency situations end-ileostomy

QUESTIONS ??????

References ƒ Baumgart DC, Sandborn WJ. “Inflammatory Bowel Disease: clinical aspects and evolving therapies.” Lancet. 2007;369:1641-57. Cima RR and Pemberton JH JH. “Surgical Surgical Indications and Procedures in ƒ Cima, Ulcerative Colitis.” Current Treatment Options in Gastroenterology. 2004;7:181-190 ƒ Modigliani, R. “Medical Management of Fulminant Colitis.” Inflammatory Bowel Diseases. Diseases 2002;8(2):129-134. 2002;8(2):129 134 ƒ Bullard KM, Rothenberger DA. “Colon, Rectum & Anus.” Schwartz's Principles of Surgery. 8th Edition. ƒ S. Ian Gan and P.L. Beck. “A New Look at Toxic Megacolon: g An Update and Review of Incidence, Etiology, Pathogenesis, and Management.” The American Journal of Gastroenterology. 2003;98(11):2364-2371. H, Panthel K K, Bader RD RD, Schmitt C C, Schaumann R R. ƒ Rüssmann H “Evaluation of three rapid assays for detection of Clostridium difficile toxin A and toxin B in stool specimens.” Eur J Clin Microbiol Infect Dis. 2007 Feb;26(2):115-9 ƒ Strong, Strong Scott. Scott “Fulminant Fulminant Colitis: the case for operative management management.” Inflammatory Bowel Diseases. 2002;8(2):135-137.