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| Case of the Week Thursday 11/10/2005 |
Presented by Dr. Hany Shehab .
Ulcerative Colitis
Click here to download a power point presentation for the case.
STAFF ROUND PRESENTATION
Prof. Afaf Farag
Prof. Magdy El-Serafy
Prof. Yaser El-Borei
Shereen Hunter
Mohammed Mahmood
Hanan Abdel Hafez
Alaa Hassib
Mohammed Elsayed
Yehia Elsherif
Ehab Adel
Hany Shehab
Personal data:
• Walid Aly Aly, 29 years old
• Born and living in Hawamdeya, Giza
• Married for 4 years, has 2 children, youngest 1 year old
• Shoe repair man
• Smoker 20 cigarettes/day for 8 years, stopped 3 months ago.
• No history of contact with canal water or anti-bilharzial treatment.
Complaint:
Yellowish discolouration of the eyes and darkening of urine
• Jaundice
Appeared 4 years ago. Gradual onset over 1 month, followed by an intermittent course over the following years. Darkening of urine was first noticed followed by jaundice, normal coloured stools.
He noticed exacerbations of jaundice with occasional attacks of fever with rigors, but not associated with abdominal pain or pruritus.
• No manifestations of anaemia ( no pallor, dyspnea, palpitations, dizziness, bony aches, leg ulcers, pigmentation.)
• No other manifestations of hepatic dysfunction ( no abdominal distension, oedema of lower limbs, bleeding tendency, haematemesis or melena, DCL.)
• No epigastric or back pain or marked weight loss.
• No bleeding per rectum, diarrhea, oral ulcers or skin lesions.
• No xanthomas, xanthelasmas, bony aches, recent fracures or steatorrhea.
• Past history:
No DM or Hypertension
No history of drug intake or alcohol consumption.
No history of operations or blood transfusion.
• Family history: of no significance.
Summary
INTERMITTENT JAUNDICE FOR 4 YEARS.
Examination
• Jaundice Vital signs : Bp: 120/750
No pallor Pulse:80
No xanthomas temp.: 37.0
No spider naevi
No palpable lymph nodes
No thyroid enlargement
No ecchymotic patches
No lower limb oedema.
• Chest & Heart examination : free
• Abdominal examination :
Not distended, no divarication of recti ,umbilicus not shifted, no impulse on cough
Liver: Not palpable.
Spleen: Not palpable
No ascites detected
Differential Diagnosis
• Hepatocellular jaundice:
Viral hepatitis ( Chronic B&C)
Drug induced hepatitis
Other forms of hepatitis (Autoimmune, Wilson's disease)
Hereditary ( Dubin-Johnson, TypeI CN, PFIC III)
• Cholestasis
Extrahepatic (calcular?)
Intrahepatic:
Primary sclerosing cholangitis
Autoimmune Cholangitis
Benign recurrent intrahepatic cholestasis
Primary biliary cirrhosis
• Haemolytic: ( with intravascular haemolysis)
G6PD
PNH
Investigations
• Urinalysis:
proteins: +
Glucose: nil
bile pigments: ++
urobilinogen: +
pus cells: 3-5
RBC's: 1-2
crystals: Ca oxalate (few)
casts: nil
ova: nil
• CBC: " Normal CBC"
WBC's: 10.6
eosin : 1
lymph: 30
staff: 1
seg: 63
mono: 5
bas: 0
RBC'S: 4.8
HGB: 13.9
MCV: 91
MCH: 29
MCHC: 32
Platelets: 276,000
• ESR: 70 1st hour
110 2nd hour
• Liver chemistry:
Bil-T: 5.6
Bil-D: 3.5
AST: 62 (n: up to 41)
ALT: 81 (n: up to 41)
ALP: 640 (n: up to 104)
GGT: 322 (n: up to 50)
T.proteins: 8.0 (n: 6.6-8.7)
Albumin: 3.5 (n:3.5-5.5)
urea: 16
creatinine: 0.72
• Prothrombin conc.: 78%
INR: 1.3
• Viral markers :
HBsAg: -ve
HBcAb total: -ve
HBsAb :-ve
Anti-HCV Ab: -ve
• Ultrasound:
Liver: Mildly enlarged with normal surface, uniform bright echopattern. No definite focal areas. There is mild central IHBR dilatation. Main portal vein is not dilated measuring 11mm.
Gall bladder: Average size with normal wall thickness. No calculi or mud seen. CBD is not dilated
Spleen: Size is at upper limit of normal (longest axis 13cm.)
Kidneys: normal
Pancreas: free
NO ascites.
CONCLUSION
Mild bright hepatomegaly
Mild central IHBR dilatation
• ERCP :
Cannulation of CBD with injection of contrast material showed that it is beaded with beaded IHBR'S where cystic dilatation was seen in some segments.
Picture suggestive of sclerosing cholangitis
• LIVER BIOPSY
Preserved lobular architecture. Hepatocytes were arranged in regular thin plates within the lobules, they showed no significant morphological alteration or evidence of cholestasis. The sinusoids showed mild focal dilatation.
Two portal areas were detected in the specimen, they showed no significant abnormality.
No evidence of specific pathological alteration was detected in the specimen received.
• P-ANCA:
Negative
• CA19-9:
0.0 mIU/ml
• COLONOSCOPY
Colonoscopic examination up to the terminal ileum was done and revealed:
• The mucosa of the colon from the rectum up to the caecum showed diffuse ulcerations with friable easily bleeding mucosa on touch and few scattered small sessile polyps at different colonic segments, the lesions are more severe in the recto-sigmoid mucosa (biopsied)
• COLONOSCOPY (continued..)
• Pathology :
Examination of ileal and rectal specimens revealed focally ulcerated mucosa with edematous congested lamina propria showing diffuse dense mixed cellular infiltrate.
There is evidence of cryptitis but no well formed crypt abscesses.
No granulomas, transmural inflammation or atypia.
CONCLUSION :
ULCERATIVE COLITIS, active phase.
TREATMENT
• High dose UDCA (20-25 mg/Kg)
(Mitchel 2001 & Angulo 2001 à improve biochemistry + delay histologic progression unlike conventional dosage 13-15mg/kg )
• Salazopyrine 4g daily
• Follow-up program :
Colonoscopy /2years
Ultrasound + Ca19-9/ 6months
Thank you
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