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Medical Grand RoundsClinical Vignette

October 8, 2008

Sabina Berezovskaya, M.D.

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.

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.

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– Lisinopril 20 mg daily– Simvastatin 40 mg daily– Metformin 1g twice a day– Pioglitazone 30 mg daily– Esomeprazole 40 mg daily

• Allergies: no known drug allergies

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.

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

Imaging

• Chest x-ray: no cardiopulmonary disease

• EKG: normal sinus rhythm with q waves in II,III, aVF; unchanged from prior baseline.

Working diagnosis

Lower Gastrointestinal Bleed

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

Colonoscopy

Pathologic Diagnosis

Poorly Differentiated Invasive Carcinoma+ for Cytokeratin 20 and Neuron Specific

Enolase (NSE)

- for Cytokeratin 7, Synaptophysin or Chromographin

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 <0.5 (nl <=5)

Abdominal / Pelvic CT Scan

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

Final Diagnosis

Lower Gastrointestinal Bleed due to

Poorly Differentiated Adenocarcinoma of the ascending colon and the hepatic flexure