A 20 Year Old Man Referred To Gastroenterologist To Evaluate For Bloody Diarrhea

A 20 year old man is refereed to a gastroenterologist by his college internist for a workup of bloody diarrhea. The patient gives a history of recurrent bouts of bloody diarrhea, abdominal pain and painful bowel movements over the past 8 months. He describes the abdominal pain to be crampy in nature and he has normal formed stools and bowel movements in between the episodes. He denies any symptoms of vomiting, constipation or urinary problems. He has no significant illnesses in the past. On Examination the patient appears to be a thin white male in no acute distress. he has diffuse mild abdominal tenderness and no organomegaly. His bowel sounds are normal. The patient is noticed to have multiple painful nodules on his anterior lower legs. Other systems are normal on examination. Rectal examination detects occult blood.

On the basis of the above history and examination what is the Differential Diagnosis:

Differential Diagnosis:

• Inflammatory bowel disease ( ulcerative colitis or crohn's disease)
• Bacterial or parasitic gastroenteritis
• Celiac sprue
• Lactose intolerance
• Whipple disease
• Irritable bowel disease
• Carcinoid tumor

X ray barium enema done in this case is shown below:

On colonoscopy highly friable colonic mucosa was seen involving the full length of the colon without interruption. 

Final Diagnosis: Ulcerative colitis

Case Discussion:

Ulcerative colitis is a variant of inflammatory bowel disease characterized by continuous involvement of a region of the colon. The disease begins at the rectum and extends to a proximal end point within the colon. 

On histopathology only the mucosal layer of the bowel is involved. 

Age of onset; It typically begins in second or third decade of life.

Clinical features:

• Abdominal pain
• Urgency of bowels
• Bloody diarrhea
• Painful bowel movements
• nausea and vomiting
• Weight loss
• Fever
• Abdominal tenderness
• Extraintestinal menifestations: arthritis, uvetits, ankylosing spondylitis, erythema nodusum, pyoderma gangrenosum, primary sclerosing cholangitis

Diagnosis: Along with the clinical history and physical examination following are seen in laboratory workup:

• Mildly increases serum WBC count
• Increased ESR and CRP
• Stool analysis frequently detects PMNs
• Barium enema shows a lead pipe colon without haustral markings and generalized shortening of the colonic length. 
• Colonoscopy demonstrates a friable mucosa and psuedopolyps in continuous fashion.
• Biopsy demonstrates inflammation limited to the mucosal layer of the bowel wall.

Treatment:

1. Aminosalicylates ( e.g mesalamine, sulfasalazine) are the first line of therapy to suppress disease activity.

2. Corticosteroids may be used in patients with disease that is not responding to aminosalicylates. 

3. Patients not responding to treatments above may benefit from immunomodulators (e.g mercaptopurine, azathioprine, infliximab)

4. Total colectomy is curative and may be performed in patients with disease that is not responding to medical treatments.