NMS. Casos Clínicos

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Chapter 8 ♦ Lower Gastrointestinal Disorders

Q: After the patient recovers from surgery, what long-term follow-up is appropriate? A: If all of the patient’s colon and rectum are removed, cancer is very rare but can occur because it is difficult to remove all mucosal cells and cancer can occur in the pouch. If residual rectal mucosa is present, proctoscopy at a 6-month-to-1-year interval is nec- essary as surveillance for colon carcinoma. (Any of the usual problems that may occur after complicated surgery could also develop, and patient should receive education about these problems.) The patient recovers from her total proctocolectomy and ileal pouch–anal anastomosis, but returns 6 months later with fever, blood-tinged diarrhea, and pain on defecation. Q: What is the most likely diagnosis? A: The suspected diagnosis is “pouchitis , ” which is an inflammation of the reservoir from an unknown cause. On endoscopy, a hemorrhagic mucosa with edema and small ulcerations is seen. This problem develops in up to half of patients with an ileal pouch. Q: What treatment is appropriate? A: Treatment is with metronidazole , which resolves the problem in the majority of patients. Case 8.12 Complications of Acute Colitis A 29-year-old patient presents with a several-month history of abdominal cramps, diarrhea, and a 5-lb weight loss of several months’ duration. Bloody diarrhea began this morning. Except for the diarrhea, the history and physical examination are unremarkable. Q: What evaluation and management are appropriate? A: The patient may have IBD. A colonoscopy is necessary to determine if the pathologic dis- ease is ulcerative colitis, Crohn colitis, or some other process. Ulcerative colitis typically affects young individuals. This disease usually begins in the distal colon and rectum and can extend proximally to involve the entire colon. Typically, it involves only the mucosa. It is characterized by crypt abscesses and raised ulcerations. Crohn disease, an inflammatory disorder, may affect any part of the GI tract from the mouth to the anus. It typically occurs as skip lesions and involves all layers of the bowel wall. Severe perineal disease, including fistula, may occur. Treatment for both diseases includes antiinflammatory medications, immunosuppressive drugs, and antibiotics. After institution of therapy, the patient stabilizes and is placed on chronic therapy and fol- lowed clinically with a diagnosis of ulcerative colitis. Two months later, the patient returns to the emergency department acutely ill, with recurrence of bloody diarrhea, abdominal pain, and distention. The temperature is 101°F, the BP is stable and normal, and the heart rate is 120 beats per minute. The abdomen is distended and acutely tender. Q: What is the suspected diagnosis? A: You would be concerned about toxic megacolon in a patient with ulcerative colitis and abdominal pain, distention, fever, and bloody diarrhea. SAMPLE