A 63YearOld Woman With Diarrhea and Abdominal Pain Chapter 19

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A 63-Year-Old Woman With Diarrhea and Abdominal
Pain Chapter 19
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

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History and Presentation

• A 63 y.o. ? admitted to hospital with chief
  complain of generalized abdominal pain, most
  severe in LLQ, chills and watery diarrhea of 10
  days duration.
• Recently diagnosed with Lyme disease treated with
  cephalosporin for 2 weeks
• No other significant medical or surgical history
• Physical Exam
• Alert ? in mild distress
• BP 114/80
• HR 90 bpm RR 20
• Temp. 101 oF
• Exam of chest - unremarkable
• Abdomen mild tenderness upper abdomen,
  remarkable tenderness in LLQ
• Rest of exam including rectal - unremarkable
• Samples for blood and stool cultures obtained
• Flat plate of abdomen
• Sigmoidoscopy performed and a colonic biopsy
  obtained

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Differential

• Possibilities that might account for this
  scenario of generalized abdominal pain and watery
  diarrhea?
• Diverticulitis
• Pseudomembranous colitis
• Irritable bowel syndrome Characterized by
  cramping, abdominal pains and changed bowel
  habits
• Celiac sprue Malabsorption injury to villous
  epithelial cells from gluten -
• E. coli infection Secretory, non-inflammatory
  diarrhea cause by entero-toxigenic toxins
• Shigella One of principal causes of dysentery
• Compylobacter jejuni Causes patchy destruction
  of the mucosa and inflammatory diarrhea, fever
  and abdominal pain
• Ulcerative colitis Inflammatory diarrhea,
  fever, and abdominal pain

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Radiology
Normal Flat Plate
Patient On Admission
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Toxic megacolon Dilation of the colon

• Toxic megacolon - dilation of the colon with
  fulminant colitis
• Moderate dilation of the colon with loss of
  haustration in the descending colon (arrow).
• Leyla Azmoun, MD Piran Aliabadi, MD and B
  Leonard Holman, MD Toxic Megacolon
• brighamrad.harvard.edu/Cases/bwh/hcache/178/full.h
  tml

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Toxic Megacolon Filling Defects

• There are polypoid filling defects in the sigmoid
  and descending colon See arrows.
• Leyla Azmoun, MD Piran Aliabadi, MD and B
  Leonard Holman, MD Toxic Megacolon
  brighamrad.harvard.edu/Cases/bwh/hcache/178/full.h
  tml

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Thickening of colon wall

• Thickening of the wall of the colon indicating
  edema is also visible arrow.
• Leyla Azmoun, MD Piran Aliabadi, MD and B
  Leonard Holman, MD Toxic Megacolon
  brighamrad.harvard.edu/Cases/bwh/hcache/178/full.h
  tml

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Differential Toxic Megacolon

• Toxic megacolon can be seen as a complication of
  the following diseases
• ulcerative colitis
• Crohn's disease
• ischemic colitis
• pseudomembranous colitis
• amebiasis
• Plain film of the abdomen is the primary imaging
  modality for diagnosis of toxic megacolon.
• Urgent medical treatment is essential.
• Timely consideration of surgical treatment if
  medical treatment fails is a must.

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HEMATOLOGY
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Shift to the Left

• Includes
• Unilobed and two lobed nucleus predominate
• Seen in
• Acute infection
• Metaboloc acidosis
• Necrosis myocardial infarct. malignant tumors
• Blood disease
• hemolytic crises,
• severe blood loss
• chronic  granulocytic leukemia,

Band cell
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CHEMISTRY
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Electrolytes
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Additional Studies
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Significance of stool examination

• gt 5 PMNs/HPF in the stool ? inflammatory process
• Viruses - MOST COMMON causes of non-inflammatory
  diarrhea
• E. coli produces toxins ? diarrhea but it is a
  non-inflammatory diarrhea. Leukocytes are
  typically absent
• Typical inflammatory causes of diarrhea include
• Shigella dysentery and bloody diarrhea
• Campylobacter jejuni patchy destruction of
  mucosa in the small and large intestines
  inflam. Diarrhea, fever and abdominal pain
• Yersinia enterocolitica similar clinical picture

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Pertinent Data Days 2 3
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Diarrhea

• Base-losing acidosis (Metabolic acidosis)
• Direct loss of HCO3- from the lumen of the small
  intestine results in acidosis
• Normally HCO3- is secreted and reabsorbed in the
  small intestine
• Prolonged diarrhea (ulceratiave colitis or severe
  dysentary) prevents reabsorption and may ? to a
  significant loss of HCO3- in the feces.
• Compensations
• Hyperventilation
• Renal excretion of the H ions combined with the
  urinary buffers, (HPO4, or NH3). HCO3 is
  regenerated in the plasma.
• Intracellular and bone buffering. H ions can
  enter cells and be taken up by the cell and the
  bone buffers (eg, proteins, phosphate, bone
  carbonate).

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CHEMISTRY Day 23
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Day 2 3
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Colonic Biopsy

• Stool positive for Clostritium difficile toxin
• Pseudomembrane arrow
• Crypt filled with inflammatory cells and mucus.
  This debris forms the pseudomembrane

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Clinical Course

• Rapid downhill course
• Development of DIC
• PT, aPTT, bleeding time fibrin degradation
  pdcts. ?
• Platelet count, fibrinogen level are ?
• Septic Shock
• Severe hypotension
• HR
• Respiratory insufficiency
• Metabolic acidosis
• Deterioration of renal function
• Tissue anoxia

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Colonic Biopsy HE x12
Ulceration
Crypt Abcess
Inflammatory infiltration of lamina propria
Tubular glands distorted, decrease in the number
of goblet cells, widened muscularis mucosa
PATIENT
NORMAL
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Gross appearance Colon at Autopsy

• Gross appearance of colon at autopsy
• Greyish-green pseudomembrane covers red mucosa

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Histology at autopsy
Distended crypt
Pseudomembrane composed of fibrin,necrotic
debris and neutrophils
Epithelium appears denuded
Bowel wall appears necrotic
Inflammatory infiltrate, muscle fibers are
becoming fragmented
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Histologic findings at autopsy
Multiple petechial hemorrhagesare visible on
ventricular septum grossly and histologically
Fibrin thrombi in capillaries beloware
consistent with diagnosis of DIC
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Case Summary

• Final Diagnosis
• Severe pseudomembranous colitis
• Toxic megacolon
• Disseminated intravascular coagulation
• Septic shock
• Consequence of cephalosporin therapy
• Watery stool with the presence of PMNs and mucus
  are very common findings in PMC
• Toxic megacolon on X-ray is consistent with PMC
• Presence of C. difficile toxins in stool and the
  findings on biopsy confirm the diagnosis.
• Toxic megacolon ? septic shock and DIC ? patient
  death on day 3.

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References

• http//www.emedicine.com/radio/topic181.htmtarget
  3
• http//brighamrad.harvard.edu/Cases/bwh/hcache/178
  /full.html

• Websites containing information on Toxic megacolon