Answer this clinical vignette.

Discussion in 'Medical Students - MD' started by qweewq11, Apr 30, 2004.

  1. qweewq11

    qweewq11 Smiley orgy organizer
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    60 yr old man comes to ER complaining of bright red blood per rectum. Bleeding began abruptly several hours ago. Has orthostatic hypotension but no abdominal pain, cramps, fever, nausea, or vomiting. No previous hx of bleeding or ab pain, but has a hx of CAD and takes aspirin as a "blood thinner." He is afebrile, slightly hypotensive, and tachycardic, but stable. On exam, decreased skin turgor and dry mucous membranes are noted. Ne has no abdominal tenderness. Rectal exam is positive for gross blood.

    What is the most likely diagnosis:
    A) Arteriovenous malformation
    b) diverticulitis
    C) infectious colitis
    d) ischemic colitis
    E) Ulcerative colitis.

    :)
     
  2. Kalel

    Kalel Membership Revoked
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    The answer is A.. Diverticuliits does not bleed (diverticulosis does), infectious colitis would present with a more prominent hx of diarrhea or abdominal pain and possibly fever, ischemic colitis would present with "pain out of proportion to exam", and ulcerative colitis would present with diarrhea and is unlikely a new dx given his age and hx of taking asa and a blood thinner.
     
  3. Idiopathic

    Idiopathic Newly Minted
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    I actually agree...no pain pretty much cinched it.
     
  4. Andrew_Doan

    Andrew_Doan Doc, Author, Entrepreneur
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    As an ophthalmologist, my answer is A. As Kalel pointed out, answers B-E will have other symptoms. ;)
     
  5. Seaglass

    Seaglass Quantum Member
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    In the interests of upping my post count, I will also say A.
     
  6. omores

    omores sleep deprived
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    Yes, I'm with A, but if internal hemorrhoid had been an option I might have had trouble choosing. Good thing it wasn't.
     
  7. Skrubz

    Skrubz Not your scut monkey
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    I concur with the above answers. From among the choices listed, the most likely cause is AVM. B-E generally have accompanying symptoms, and this patient has nothing save signs of intravascular volume depletion.
     
  8. rxfudd

    rxfudd 1K Member
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    Why is it that diverticulitis doesn't present with bleeding but diverticulosis does?
     
  9. Seaglass

    Seaglass Quantum Member
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    Diverticulitis is an inflammed diverticulum packed with feces. It doesn't bleed because . . . it's packed with feces. Diverticulosis bleeds (a lot) because the diverticulum stretches until it ruptures a blood vessel running through the wall of the diverticulum. There is no impediment to blood flow, so flow it does.

    C
     
  10. babinski bob

    babinski bob Senior Member
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    I agree with everyone else... One possible explanation is angiodysplasia of the lower GI tract which is responsible for 20% of all GI bleeds. Another (and probably more likely scenario given this pts age) is probably bleeding from a polyp/colon Ca.
     
  11. rxfudd

    rxfudd 1K Member
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    Good explanation, thanks.

     
  12. quackdoc

    quackdoc Member
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    Angidysplasia is usually in the caecal walls-there would be history of altered blood.
    Other possibilities would be associated with other symptoms.
    I d agree with the possibilty of Colonic carcinoma particularly ulcerative type that presents with fresh bleeding per rectum.
    Any history of trauma?
    Internal piles is again a possibility which cannot be ruled out.
    Crohns?Any takers for that?
    Could it also be because of Aspirin?Making the patient prone for bleeding?In that case for how long aspirin intake should be there so as to interfere with the bleeding time?
     
  13. beriberi

    beriberi Senior Member
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    dude. It's multiple choice.
     
  14. praying4MD

    praying4MD 2K Member
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    I have a pt with almost this exact history and he has cholangiocarcinoma requiring a Whipple. chew on that for a while.
     

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