Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

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Clinical Correlations The NYU Internal Medicine
BlogA Daily Dose of Medicine
http//clinicalcorrelations.org
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Medical Grand RoundsClinical VignetteOctober
8, 2008

• Sabina Berezovskaya, M.D.

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Chief Complaint

• 49 year old male presents with early satiety for
  three months and one day of red blood and clots
  mixed with stool one week prior to presentation.

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History of Present Illness

• He was in his usual state of health until three
  months prior to admission when he began
  experiencing frequent early satiety and
  subjective weight loss.
• One week prior to presentation patient noted
  bright red blood per rectum with clots which
  spontaneously resolved after one day.
• One day prior to admission, he had routine labs
  drawn at his cardiology clinic appointment.
• He was recalled for admission when his hemoglobin
  returned significantly decreased from his
  baseline.

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Further history

• Past Medical History
• GERD
• Diabetes Mellitus Type II
• Hypercholesterolemia
• Hypertension
• Coronary artery disease (CAD) with prior STEMI
  (10/07) requiring percutaneous stenting of the
  RCA
• Past Surgical History Denies
• Social History
• Prior history of alcohol abuse (20 beers per
  day). Last use 2 years ago
• No tobacco or illicit drug use
• Family History Non-contributory
• Medications
• Aspirin 81 mg daily
• Clopidogrel 75mg daily
• Metoprolol 50 mg twice a day

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Physical Exam

• General Well nourished and well developed male
  in no acute distress
• Vital signs T- 98º F BP 99/75 HR 62 RR 18
  O2 sat 100 RA
• Orthostatics were negative
• Abdomen mildly tender at the right lower
  quadrant
• Rectal no masses or tenderness black guaiac
  stool
• The physical exam was otherwise entirely normal.

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Laboratory Findings

• WBC 7.7, normal differential
• Hgb 7.9 g/dl, MCV 65.6, RDW 15.8
• Prior baseline hgb 13-14g/dl
• Platelets 384
• Iron 16 mcg/dL (nl 42-146)
• TIBC 462 mcg/dL (nl 250-450)
• Ferritin 4.8 ng/mL (nl 22-322)
• Basic metabolic panel, liver function tests,
  amylase, lipase coagulation profile were all
  within normal limits

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Imaging

• Chest x-ray no cardiopulmonary disease
• EKG normal sinus rhythm with q waves in II,III,
  aVF unchanged from prior baseline.

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Working diagnosis

• Lower Gastrointestinal Bleed

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Colonoscopy

• A single sessile polyp measure 6mm in size was
  found in the hepatic flexure.
• The polyp was removed with a hot snare
• There was a friable non-obstructing
  circumferential tumor in the ascending colon
  immediately distal to the IC valve

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Colonoscopy
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Pathologic Diagnosis

• Poorly Differentiated Invasive Carcinoma
• for Cytokeratin 20 and Neuron Specific Enolase
  (NSE)
• - for Cytokeratin 7, Synaptophysin or
  Chromographin

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Clinical Staging Evaluation

• Abdomen Pelvis CT
• Ascending colon tumor with multiple enlarged
  adjacent mesenteric lymph nodes
• Chest CT
• No evidence for intrathoracic metastatic
  disease
• CEA lt0.5 (nl lt5)

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Abdominal / Pelvic CT Scan
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Hospital Course

• Patient was transfused with 1 Unit of packed red
  blood cells and started on Iron supplementation
• He remained hemodynamically stable and had no
  recurrent episodes of bleeding
• Patient was evaluated by surgical consult and a
  right hemicolectomy was scheduled

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Final Diagnosis

• Lower Gastrointestinal Bleed due to
• Poorly Differentiated Adenocarcinoma of the
  ascending colon and the hepatic flexure