PGY2 Vivian Lee presented a case of a 63 year old male with no past medical history who presents with persistent diarrhea x25 days. He reports ~10 episodes of watery diarrhea per day, associated with cramping abdominal pain and relieved with bowel movements. Denies any melena or hematochezia. Denies abdominal pain, fevers, chills, weight loss, nausea/vomiting, dysphagia/odonophygia. No recent travel, antibiotic use within the past 3 months, sick contacts or previous history of diarrhea. He drinks bottled water and buys his food from stores. He presented to the ED one week ago for similar symptoms and was discharged with loperamide. He also notes new onset sharp rectal pain for past 3-4 days that is worse with bowel movements. No home medications beside loperamide and no family history of malignancy or IBD. He is homeless, living on the streets. Denies any tobacco/illicit drug use. Drank 1-2 beers per day for the past year, now currently sober.
Vitals: T 37.8, HR 125, RR 24, BP 130/79, O2 sat 98% on RA
Physical Exam significant for A&Ox4, obese Hispanic male, +conjunctival pallor, normal cardiac and pulmonary exam, soft abdomen, nontender with normal bowel sounds, no skin rashes. DRE with superior midline perianal fistula with pus drainage, +intergluteal erythema, no blood.
CBC: WBC 14> Hb 10.9/Hct 34.2 <Plt 510 (MCV 82.9, RDW 16.1%)
Na 134/K 4.1/Cl 97/HCO3 23/BUN 5/Cr 0.7<Glucose 101
ALP 75>T.protein 5.5/Albumin 2.8/AST 20/ALT 21/Tbili 0.3/Dbili <0.2
Ca 8.5, Mg 2.1, Phos 3.7
Coags: PT 15.1, INR 1.21
Infectious workup initiated, with the following findings:
- BCx, UA negative
- Stool culture negative
- Stool O&P negative
- C. diff unable to be performed due to formed stools
- HIV negative
- E. histolytica negative
- Hepatitis panel negative
- Wound culture from perirectal abscess: 3+ streptococcus mitis/Streptococcus oralis, 3+ mixed normal flora
GI workup initiated:
- CRP and ESR elevated
- Fecal calprotectin >2000
- CEA 50.6 (normal <3.8)
- CTAP w/ contrast: focal nodular wall thickening of the rectosigmoid colon with heterogeneous mural enhancement, adjacent edema and fat stranding as well as small to upper limits of normal in size indeterminate mesenteric lymph nodes. Diffuse colonic diverticulosis.
- Colonoscopy done with findings of two synchronous masses in sigmoid colon and rectum, concerning for malignancy, with appearance not consistent with IBD.
Path: pT3N0MX rectosigmoid adenocarcinoma
Treatment: Patient started on IV CTX/Flagyl given initial concerns of sepsis. After findings from colonoscopy, CRS consulted and patient underwent sigmoidectomy and LAR.