Bloody Diarrhoea and Frequency
Try out this gastrointestinal case and test your clinical knowledge. The answers are at the bottom.
Questions
You are an FY1 in A&E. A 32-year-old woman presents with a one-week history of bloody diarrhoea, urgency and fatigue. She reports opening her bowels up to 10 times a day, passing stool that is very loose and has large amounts of blood mixed in. She reports left-sided abdominal pain that was initially relieved by opening her bowels but has now become more constant. She feels generally tired and unwell but has not lost any weight. She denies any recent travel, takeaways or illnesses requiring antibiotics. She reports several similar episodes of symptoms over the past 6-months which were self-limiting.
She has no past medical history and takes no regular medication. She reports that her mother suffers with ‘bowel issues’. On examination, she is tender in the left iliac fossa. A PR examination revealed no palpable masses and an empty rectum.
Observations
BP 102/75
HR 130
Sats 100% on air
RR 14
Temp 37.5
Bloods
Hb 98, WCC 11.1, Plt 450
Na 142, K 4.3, Ur 3.5, Cr 75, eGFR > 90
ALT 12, ALP 34, Bil 7, Alb 36
CRP 15.7, ESR 23
Β-HCG < 2
Q1: What initial imaging test would you request?
The patient’s imaging test is unremarkable, and her abdominal pain is relieved by some Paracetamol. Your registrar requests you to send off the appropriate stool tests.
Q2: What stool tests would you request?
The nursing staff are wondering if this patient requires admission to hospital.
Q3: What is the likely diagnosis? What criteria would you use to determine if this patient requires admission?
The patient is accepted for admission to the acute medical ward.
Q4: What is the most appropriate initial management of this patient?
As part of your management plan, you organise a flexible sigmoidoscopy to get imaging of the patient’s large bowel. The images are below.
BONUS QUESTION: Based on the imaging findings, and given the likely diagnosis, what long-term treatment is indicated in this case?
Answers
Reveal the Answers
Answer to Question 1
The most appropriate initial imaging test is an Abdominal X-Ray to rule out toxic mega-colon, given that the patient has left-sided abdominal pain, tachycardia, a raised white cell count and anaemia. Inflammatory or infectious colitis can acutely cause toxic megacolon, which is a condition associated with high morbidity and mortality. The criteria for diagnosing toxic-megacolon include colonic distension above 6cm on radiological imaging and at least three of the following features:
- Fever > 38.6
- Heart rate > 120
- WCC > 10.5
- Anaemia
If toxic-megacolon is present, the patient should be monitored closely with medical management for 72-hours, and an urgent surgical opinion should be sought if there is suspicion of complications such as perforation or massive rectal bleeding.
Answer to Question 2
An infectious cause should always be ruled out in patients with diarrhoea, so a faecal microscopy and culture (MC+S) or faecal PCR for enteric pathogens should be sent. If there is a history of recent travel or consumption of contaminated food, a faecal ova, cysts and parasites screen should be sent. If there is a history of recent or recurrent broad-spectrum antibiotic use, a faecal c-difficile screen should be sent (particularly for elderly hospital inpatients). A faecal calprotectin level should also be sent to investigate for inflammation, noting that this would be raised in both infectious and inflammatory colitis. A baseline calprotectin value is useful to assess for clinical response in inflammatory bowel disease.
Answer to Question 3
The most likely diagnosis is inflammatory bowel disease (IBD), such as Ulcerative Colitis (UC), given the relapsing and remitting course of disease, left-sided abdominal pain associated with bloody diarrhoea and urgency. This patient also likely has a family history of IBD, highlighting a potential genetic risk factor.
The Truelove and Witts criteria can be used to assess the severity of a UC flare. This factors the patient’s stool frequency, volume of blood in the stool, heart rate, temperate, anaemia and inflammatory markers (CRP and ESR). UC severity is categorised into ‘mild’, ‘moderate’ or ‘severe’ using these markers. In general, mild-to-moderate flares can be managed conservatively in the community and severe flares require admission to hospital.
Answer to Question 4
This patient should be started on intravenous steroids (hydrocortisone) at a dose of 100mg QDS. Her care should be discussed with the gastroenterology team. She should also have a flexible sigmoidoscopy within 24 hours of presentation to visually assess the bowel and obtain biopsies to confirm the diagnosis histologically.
Answer to BONUS QUESTION
This patient should be commenced on 5-ASA treatment with Mesalazine. This can be administered orally, rectally (using suppositories or enemas) or both. In severe cases, patients might be escalated directly to immunosuppressive biologic therapies such as Infliximab (anti-TNF monoclonal antibody). Mercaptopurines such as Azathioprine can also be used in the long-term management of IBD.
Sources
Image 1: Tofacitinib-Associated Iatrogenic Kaposi Sarcoma in a Patient With Ulcerative Colitis – Scientific Figure on ResearchGate. Available from: https://www.researchgate.net/figure/Sigmoidoscopy-findings-of-active-ulcerative-colitis-show-marked-erythematous-mucosa-lack_fig1_356482846 [accessed 17 Jan, 2024]
Dr Abhirami Gautham
St Mark’s hospital, London
St Mark’s hospital, London
About The Author
This clinical case is written by Dr Abhirami Gautham, a gastroenterology registar working at St Mark’s hospital London, with a specialist interest in inflammatory bowel disease.
Disclaimer
The intended purpose of this website is to be used as a resource for revision for exams. It should not be used as a guideline or reference for clinical practice/decision making or by patients looking for medical information or advice. In2Med takes no responsibility for any loss or damaged resulting from the use of information from this website.
