Nguyen_Case of Bloody Diarrhea.pdf

A CASE OF BLOODY DIARRHEAResident: Quang Nguyen, MD

Attending: Muneeb Ahmed, MD

Program: Beth Israel Deaconess Medical Center, Boston, MA

CHIEF COMPLAINT & HPI

▪Chief Complaint ▪ 37-‐year-‐old male who presents with abdominal pain and blood diarrhea

▪History of Present Illness ▪Symptoms started approximately one month ago, initially with constipation and progressed to abdominal pain and watery diarrhea

▪ Initially diagnosed with uncomplicated diverticulitis and treated with antibiotics

▪Symptoms persisted and progressed to severe abdominal pain, decreased oral intake and hourly bloody diarrhea

RELEVANT HISTORY

▪ Past Medical History ▪ None.

▪ Past Surgical History ▪ None

▪ Family & Social History ▪ Denies history of Inflammatory bowel disease, gastrointestinal malignancy, or autoimmune disease

▪ Review of Systems ▪ Negative except per HPI

▪Medications ▪ Dilaudid, Ativan and Ciprofloxacin

▪ Allergies ▪ Nickel

DIAGNOSTIC WORKUP

▪Physical Exam ▪ Vital Signs: T: 98.0 HR: 86 BP: 115/70 RR: 18 SaO2: 98% on RA ▪ General: young male, no acute distress, resting comfortably ▪ Abdominal: Palpable tender masses within the left upper and lower quadrant; soft, non-‐tender in the right abdomen without peritoneal signs ▪ Rectal: no perianal lesions, no stool on digital rectal exam ▪Otherwise, negative physical exam findings

▪Laboratory Data

59921.814.0

41.9

DIAGNOSTIC WORKUP

1) What are the salient imaging findings?

A: Small colonic outpouchings with irregular wall thickening and pericolonic fat stranding

B: Circumferential, symmetric colonic wall thickening, luminal narrowing and fascial thickening.

C: Focal asymmetric colonic mural thickening with luminal narrowing

D: Small, oval pericolonic fatty nodule with hyperdense ring and surrounding inflammation

CORRECT






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SORRY, THAT’S INCORRECT






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DIAGNOSTIC WORKUP

▪ Initially diagnosed with colitis, likely inflammatory spanning from rectum to splenic flexure (i.e. Ulcerative Colitis)

▪Colonoscopy Erythema and congestion in the rectum & sigmoid colon with biopsy of sigmoid colon

▪Pathology Colonic mucosa with ischemic-‐type injury

DIAGNOSTIC WORKUP

DIAGNOSTIC WORKUP


A: Contrast blush that takes upon a rounded shape

B: Focal tangle of vessels centered in the mesentery.

C: Dilated arteries with prominent accumulation of contrast material in the bowel parenchymal

D: Abnormal clusters of small arteries with intense opacification of the bowel wall

CORRECT!


A: Contrast blush that takes upon a rounded shape.




Continue with case

SORRY, THAT’S INCORRECT.


A: Contrast blush that takes upon a rounded shape.




Continue with case

DIAGNOSTIC WORKUP

-‐ Focal tangle of abnormal vessels involving a sigmoidal artery centered within the mesentery & an early draining dilated marginal vein (which fills well before mucosal vessels fill) -‐ Finding is most consistent with a focal arteriovenous malformation with associated shunting.

INTERVENTION

Two 4 mm x 8 cm coils were sequentially placed to focally occlude the marginal artery at the site of AVM shunting. No significant filling of the major portion of the AVM.

CLINICAL FOLLOW UP

▪Clinically improved with decrease in frequency of diarrheaand resolution of bloody bowel movements

▪Sigmoidoscopy ▪ Abnormal mucosa with erythema and congestion

▪Pathology ▪ Colonic mucosa with crypt regeneration, focal crypt atrophy & and basal apoptotic debris. ▪Overall features are in keeping with an ongoing ischemic type injury including demand related vasculitis.

▪Underwent uncomplicated left hemicolectomy & end transverse colectomy

SUMMARY & TEACHING POINTS

▪ Inferior mesenteric arteriovenous malformations (AVMs) are rare with less than 15 reported in the English literature

▪AVMs can be classified as congenital or iatrogenic, secondary to abdominal trauma or colonic resection.

▪Common clinical symptoms and signs of inferior mesenteric AVMs include abdominal pain, mass or bruit.

▪Serious manifestations of mesenteric AVMs include signs of portal hypertension such as variceal bleeding, ascites and splenomegaly, which is present in approximately 50% of patients with splanchnic AVMs ▪May result from increased blood flow into the portal system and compensatory increase in hepatic vascular resistance.

SUMMARY & TEACHING POINTS

▪Patients less commonly present with symptoms of non-‐occlusive ischemic colitis (i.e. abdominal pain, diarrhea, hematochezia). ▪ This is thought to be due to a steal phenomenon from decreased arterial blood flow to the colon beyond it and increased venous pressure distal to it.

▪Transcatheter embolization has been most useful in patients who are critically ill.

▪ If treatment with embolization fails, colectomy may be necessary. Surgical resection of the AVM and abnormal bowel segment has been the treatment of choice.

REFERENCES & FURTHER READING

▪ Justaniah AI, et al. Congenital Inferior Mesenteric Arteriovenous Malformation Presenting with Ischemic Colitis: Endovascular Treatment. J Vasc Interv Radiol. 2013 Nov;24(11):1761-‐3.

▪ Turkvatan A, et al. Inferior mesenteric arteriovenous fistula with ischemic colitis: multi-‐ detector computed tomographic angiography for diagnosis. Turk J Gastroenterol 2009; 20:67–70.

▪ Jung JO, et al. Ischemic colitis associated with segmental arteriovenous malformation mimicking inflammatory bowel disease in a familial adenomatous polyposis patient. Dig Dis Sci. 2007;(52): 2703–2706.

▪ Metcalf DR, et al. Ischemic colitis: an unusual case of inferior mesenteric arteriovenous fistula causing venous hypertension. Report of a case. Dis Colon Rectum 2008; (51):1422–144.

▪ Nemcek AA Jr, et al. SIR 2005 Annual Meeting film panel case: inferior mesenteric artery-‐to-‐inferior mesenteric vein fistulous connection. J Vasc Interv Radiol 2005;16:1179–1182.

Nguyen_Case of Bloody Diarrhea.pdf

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