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Chronic diarrhoea in an elderly woman

BMJ 2011; 342 doi: http://dx.doi.org/10.1136/bmj.c7339 (Published 31 March 2011) Cite this as: BMJ 2011;342:c7339
  1. Jacqueline K Simpson, foundation year 1 trainee,
  2. Anna L Timmis, foundation year 2 trainee,
  3. Shahab Siddiqi, consultant colorectal surgeon
  1. 1Chase Farm Hospital, London EN2 8JL, UK
  1. Correspondence to: J K Simpson jacquelinesimpson{at}doctors.org.uk

An 89 year old woman was admitted with a six week history of severe watery brown diarrhoea. She had not travelled recently or changed her diet, but she had lost half a stone (3 kg) in weight. She had a history of diverticulosis, recurrent urinary tract infections, and hypertension but no family history of cancer. She was a non-smoker who lived alone and was independently mobile with a frame, requiring no package of care.

On examination she was afebrile, her pulse was 95 beats/min, and her blood pressure was 150/88 mm Hg. Her abdomen was soft and non-tender. Per rectal examination and a plain abdominal film were unremarkable. Bloods on admission showed raised inflammatory markers, and within days of admission her electrolytes became deranged, with hypernatraemia (sodium 158 mmol/L) and hypokalaemia (potassium 2.5 mmol/L). Blood gas results showed a metabolic alkalosis (pH 7.52, pCO2 37 mm Hg, bicarbonate 31 mmol/L) and hyperchloraemia (chloride 116 mmol/L). Cloudy urine, which was positive for Escherichia coli, was collected after insertion of a urinary catheter. Stool culture and Clostridium difficile toxin were negative. Flexible sigmoidoscopy showed sigmoid diverticulosis, and a random biopsy showed a mild increase in chronic inflammatory cells.

Figures 1 and 2 show axial and sagittal computed tomograms of the abdomen

Fig 1 Axial computed tomogram of the abdomen

Fig 2 Sagittal computed tomogram of the abdomen

Questions

  • 1 What abnormality is seen on the computed tomogram of the abdomen?

  • 2 What are the differential diagnoses and the most likely diagnosis in this case?

  • 3 Can you explain the electrolyte derangement?

  • 4 What …

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