Endgames Case Report

A man with bloody diarrhoea

BMJ 2012; 344 doi: http://dx.doi.org/10.1136/bmj.e978 (Published 07 March 2012) Cite this as: BMJ 2012;344:e978
  1. Jonathan W Hinton, foundation year 2 trainee doctor, gastroenterology ,
  2. J R Fraser Cummings, consultant gastroenterologist
  1. 1Southampton University Hospitals NHS Trust, Southampton SO16 6YD, UK
  1. Correspondence to: J R F Cummings fraser.cummings{at}suht.swest.nhs.uk

A 32 year old man with known ulcerative colitis and ankylosing spondylitis was admitted with diarrhoea (at least eight stools per 24 hours) mixed with blood and mucus. He also had lower abdominal pain, lethargy, and was feeling feverish. On examination he was afebrile, had a pulse of 90 beats/min, and was tender in his left iliac fossa. Blood tests on admission showed haemoglobin 111 g/L (reference range 120-150), platelets 453×109/L (150-400), international normalised ratio 1.5, C reactive protein 205 mg/L (0-7.5), sodium 127 mmol/L (136-144), potassium 3.6 mmol/L (3.5-5.0), albumin 25 g/L (35-48).

On admission he was taking balsalazide 2.25 g three times daily for stable ulcerative colitis. He had never been admitted to hospital for ulcerative colitis and had not received antibiotics.

The patient underwent flexible sigmoidoscopy, which showed severe ulceration in the rectum.

On day 3 he was passing stools—which were mixed with blood—six times a day, he was still tender in his right iliac fossa, and he had a temperature of 38°C. His C reactive protein was 119 mg/L.

Questions

  • 1 What is the likely diagnosis, and what other diagnoses need to be considered in a patient with bloody diarrhoea?

  • 2 What criteria would you use to assess the severity of this condition?

  • 3 What other disease activity related symptoms might be seen?

  • 4 What are the medical management options?

  • 5 What are the surgical management options?

Answers

1 What is the likely diagnosis, and what other diagnoses need to be considered in a patient with bloody diarrhoea?

Short answer

A relapse of ulcerative colitis is the most likely diagnosis, but other diagnoses that must be considered include infectious causes, ischaemic colitis, diverticular disease, and cancer.

Long answer

This is probably a flare of ulcerative colitis. Infectious causes should also be considered and excluded, including bacterial (Clostridium difficile, Salmonella spp, Shigella spp, Campylobacter spp, Escherichia coli 0157, amoebae,1 2 and viruses such as cytomegalovirus. He could possibly have …

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