Prepared by Porf. Dr. Zakaria Salama .

Presented by Dr. Marwa Khairy.

Click here to download a power point presentation for the case.

Staff round presentation

Unit Members:

PROF. DR. Zakaria Salama UNIT

• Professor Dr.Zakaria Salama

• Assist. Professor Dr.Rabab Fouad.

• Dr.Salwa Mokhtar.

• Dr.Ahmed Salama.

• Dr.Ahmad Nabil.

• Dr.Samar Kamal.

• Dr.Basel Ebeid.

• Dr.Manal Kamel.

• Dr.Mohamed El Menasy.

• Dr.Atef Gamal El Din.

• Dr.Basem Amin.

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PERSONAL HISTORY

•  Male patient, 46y old.

•  He ' s born and living in Elmenia governorate.

•  He ' s working as a farmer.

•  He ' s married for 26years, father of 3, the youngest is 9years old.

•  He ' s a cigarette smoker 10 cigarettes per day for 25years.

•  History of contact with canal water, with no antischistosomal ttt received.

COMPLAINT

Diarrhea of 4months duration

HISTORY OF PRESENT ILLNESS

•  The condition started 4 months ago by watery diarrhea (6 – 8motions daily) not related to meals and awakened the patient from sleep.

•  Stool was watery, containing excessive mucus, no blood and with no special contents, not associated with tenesmus or dysentery.

The condition is associated with:

•  Intermittent colicky pain, mainly in the flanks, improving with defecation, partially improved by antispasmodics.

•  Insignificant weight loss (3 - 4Kg) through the last 4months associated with anorexia.

The condition is not associated with:

•  Fever and rigors.

•  Perception of body masses.

•  Other systems affection.

•  The patient sought medical advice several times and received treatment in the form of antispasmodics and antibiotics with no remarkable improvement.

PAST HISTORY

•  No history of surgical operations.

•  No history of blood transfusion .

•  No history of diabetes or hypertension.

•  No history of drug intake.

•  No history of traveling abroad.

FAMILY HISTORY

The brother of the patient had also recurrent attacks of diarrhea for more than one year and was diagnosed as intestinal lymphoma and received chemotherapy for more than 6months!!

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Summary

Diarrhea for 6months.

Colicky pain.

Family history: Intestinal lymphoma.

D.D. of chronic diarrhea:

•  Infections: Parasitic, T.B., â €¦

•  Malabsorption syndromes: Celiac disease, â €¦

•  Maldigestion syndromes: Chronic pacreatitis, â €¦

•  Inflammatory: UC, CD, microscopic colitis, eosinophilic gastroenteritis, â €¦

•  Neoplastic: Lymphoma, carcinoid, gastrinoma, medullary carcinoma of the thyroid, â €¦

•  Others: IBS,amyloidosis,hyperthyroidism, â €¦

Examination

General examination:

•  Patient is conscious, alert, cooperative, lying flat comfortable in bed, average body weight.

•  Vital signs:

- Blood pressure: 120/80.

- Pulse: 80/ min, regular.

- Temperature: 37 ° C .

•  No signs of vitamin deficiency.

HEAD AND NECK

•  No pallor, jaundice or cyanosis.

•  No palpable lymph nodes.

•  Trachea central.

•  Thyroid gland not felt.

•  Neck veins are not congested.

•  No oral ulcerations or pigmentations.

UPPER LIMBS

•  No pallor

•  No clubbing

•  No cyanosis

•  LOWER LIMBS

•  No edema

ABDOMINAL EXAMINATION

•  Normal shape and contour

•  Subcostal angle: not widened.

•  No divarication of recti.

•  Umbilicus: normal shape and position.

•  No dilated veins or pigmentation.

•  No hernias.

•  No scars of previous operations.

•  No tenderness, no rigidity, no masses detected.

•  LIVER :

- Upper border : 5th space mid clavicular line.

- lower border: not felt .

•  SPLEEN : not felt and Traub ' s area is resonant.

•  ASCITES : not detected clinically.

•  PR examination : Free.

CVS, CHEST, NEUROLOGICAL, MUSCLOSKELETAL EXAMINATION : FREE

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Investigations

STOOL ANALYSES (routine & special stains)
( DONE FOR 3 SUCCESSIVE DAYS )

Physical properties:

•  Colour: brown

•  Odour: offensive

•  Consistency: formed

•  Blood: no

•  Mucus: excessive

•  Worms : no

Microscopic examination

•  Pus cells: few

•  RBCs: no

•  Fat cells: some

•  Vegetable cells: some

•  Parasitic ova: no

•  Protozoal vegetative: no

•  Protozoal cysts: no

CBC: normal

•  WBCs

•  Total: 11.500

•  B= 1

•  E= 2

•  St= 5

•  Seg= 54

•  Lymph= 36

•  Mon= 2

LIVER BIOCHEMICAL PROFILE

•  BIL-T : 0.76 (0.1-1.1)

•  AST : 22 (0-41)

•  ALT : 29 (0-41)

•  GGT : 25 (7 – 32)

•  ALP : 72 (35-104)

•  ALBUMIN : 4.1 (3.5-5.5)

•  TOTAL PROTEIN : 7.3 (6.5-8.7)

•  PC: 90%

•  ESR: (1st hour) 10

•  Creatinine: 0.75

•  Urea: 28

•  Na: 139

•  K: 4.3

ABDOMINAL ULTRASONOGRAPHY

•  LIVER: average in size, homogenous texture, smooth surface and normal hepatic veins. No focal lesions or IHBR dilatation. PV is not dilated. Mild portal tract thickening.

•  GALL BLADDER: average size and wall thickness, no stones or mud seen inside. CBD is not dilated.

•  SPLEEN : average size (longest axis 10.5cm), homogenous echopattern.

•  KIDNEYS : both are of average size, and parenchymal echogenicity, no typical calculi or back pressure changes.

•  PANCREAS & midline structures are free.

•  NO ASCITES .

•  No abdominal lymphadenopathy.

•  No evident masses or bowe ldilatation.

•  CONCLUSION: Mild portal tract thickening.

UPPER GI ENDOSCOPY

•  OESOPHAGUS: Normal

•  STOMACH: The mucosa of the antrum, body and the fundus is free

•  PYLORIC RING: Rounded and regular

•  DUODENUM: free down to the second part

•  CONCLUSION: Normal upper endoscopic findings.

•  DUODENAL ASPIRATE: negative.

Barium meal follow through:

•  Free flow of the injected contrast along the different portions of the stomach without delay or obstruction.

•  No intramural masses, ulcerations or diverticular outpouching.

•  Conclusion : normal study.

•  HIV: -ve.

•  Chest x-ray, Tuberculin test: -ve, ZN in stool: -ve.

•  Antigliadin and antiendomysial antibodies: -ve.

•  LDH : 221 (240-480)

•  CEA: 1.5 (0 – 5.4ng/ml)

•  CA 19.9: 5 (< 37u/ml)

Colonoscopy:

•  Colonoscopic examination up to the terminal ileum was done with no detected abnormalities of the examined mucosa, multiple biopsies were taken for histopathological examination.

Biopsy:

•  Gross:

Multiple small pieces of greyish white tissue, totally submitted.

•  Microscopic:

Colonic biopsy with preserved mucosal glands pattern and secretion. Lamina propria is infiltrated by large number of lymphocytes, no abnormal cells detected. No atypia or malignancy seen in the examined sections.

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Conclusion:

Picture compatible with the diagnosis of:

Lymphocytic colitis

Normal colonic histology:

•  Patient received treatment in the from of: Mesalazine 3 gram daily.

•  Marked improvement of the symptoms (motions 2-3 daily, well formed stool) after starting the treatment by 2months .

Thank you

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