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  #1  
Old 09-01-2012
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GIT 65 Yr Woman with Painless Rectal Bleeding!

A 65 yr old woman presents after having two episodes of rectal bleeding mixed with stool in the last 2 weeks. She does not have abdominal pain, nausea or vomiting. She has a history of HTN, DM and hypercholestrolemia. Her temp 98F, BP 140/80 mmHg, pulse 80/min and Resp 16/min. Physical examination shows a systolic ejection murmur in the right second intercostal space. Abdominal and rectal examination are benign. Her laboratory findings are shown below:
Hb 11.1 g/dL
MCV 90 fL
BUN 34 mg/dL
Creatinine 1.9mg/dL
Colonoscopy done two years ago was normal except for two hyperplastic polyps in the descending colon which were removed. Which if the following is the most likely diagnosis

A. Colon cancer
B. Diverticulosis
C. Ischemic colitis
D. Hemorrhoids
E. Angiodysplasia
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i'd go with E. angiodysplasia, as she doesn't have fecal occult blood to suggest colon ca. ischemic colitis would cause abdominal pain. diverticulosis wouldn't cause that much blood loss? also seeing she's got aortic stenosis and its association with answer E...
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would go for B.......painless rectal bleeding...high prevalence in elderly
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B.) diverticulosis: since this is the most common, moreover, rectal exam is benign: this can rule out hemorrhoid
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ans is E ........... angiodysplasia is most commonly missed on colonoscopy and causes painless bleed

diverticulosis has LLQ pain ...
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I would go for E Angiodysplasia, it fits with the scenario presented and is Associated with Aortic Stenosis which this patient has.
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Quote:
Originally Posted by absolutjag9 View Post
as she doesn't have fecal occult blood to suggest colon ca.
she has frank blood mixed with stool...........If she hasn't had a negative colonoscopy I would have gone with Ca colon since in her age group any painless rectal bleeding mixed with stool is Ca colon unless proven otherwise.

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Originally Posted by absolutjag9 View Post
diverticulosis wouldn't cause that much blood loss?
What? where is all that info coming from?
Diverticulosis can cause severe bleeding since it is due to erosion of an arteriole.
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Diverticular bleeding may be massive and life-threatening since diverticula often form at the site of arterial vascular penetration. The bleeding is usually painless except for mild crampy abdominal discomfort due to colonic spasm from intraluminal blood.
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E! Wen ever u see normal colonoscopy and Aortic Stenosis=angiodydplasia cuz mostly its missed on colonoscopy
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IMHO, Angiodysplasia!

Aortic stenosis + Painless bleed (Possible angiodysplasia) = Heyde's Syndrome!
Classic association.

Diverticulosis is a good option but d/t the presence of AS, i'd go fo angiodysplasia!
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Quote:
Originally Posted by rocketprinciple View Post
IMHO, Angiodysplasia!

Aortic stenosis + Painless bleed (Possible angiodysplasia) = Heyde's Syndrome!
Classic association.

Diverticulosis is a good option but d/t the presence of AS, i'd go fo angiodysplasia!
Yes Right.

Answer E. Angiodysplasia

Angiodysplasia can occur throughout the Gastrointestinal trat ,but most common in colon and particularly in cecum.It is most common in patients 65 years or older.Angiodysplasia can be seen on colonoscopoy although it can be missed on colonoscopy..Angiodysplasia can present as either episodic bleeding or chronic occult bleeding.A potential clue to the diagnosis in this patient is the systolic ejection murmur at the second intercostal space ,most likely representing aortis stenosis.There is a controversial association between aortic stenosis and bleeding from angiodysplaisa.

Choice A. Colon cancer is unlikely in this patient given that her prior colonoscopy just 2 years ago and only demonstrated hyperplastic polyps, which do not generally have malignant potential

Choice B. Diverticulosis if this were the cause of this patient's bleeding one would expect diverticuli to have been present on her recent colonoscopy

Choice C.Ischemic colitis is unlikely in this patient given the lack of abdominal pain, a recent hypotensive event or arrhythmia

Choice D Hemmorrhoids are often detected on rectal exam if they are contributing to lower GI bleeding
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I agree with your reasoning/answer....I have seen this asked in a different way and I have seen the question with angiodysplasia before and they wouldn't have put aortic stenosis in there...the hyperplastic polyps were removed and are a distractor

in addition to that...in the elderly 2 mc causes of rectal bleeds hemorrhoids or diverticulosis...

hemorrhoids can give you painless rectal bleeding and hypotension to the point of syncope...so if there is only bleeding and hypotension and no other information then it will be hemorrhoids....also here the DRE is benign so forget hemorrhoids

diverticulosis gives massive bleeding and LLQ pain and cause hypotension and can cause syncope...here it says NO abdominal pain...so rule out diverticulosis right away...even when I was in surgery and ER both times the elderly presented with abdominal pain

ischemic colitis in addition to that the person will have pain out of proportion...with cardiac history of CABG or Afib, endocarditis, atrial myxoma, intestinal angina (post-prandial) the person will have weight loss and will want to avoid this pain and of course gross blood in the stool

and colonic cancer pt will have bleeding and pencil thin stools and crampy abdominal pain, obstipation because left sided obstruction, right sided will give you bleeding, weight loss, A/N/V

I hope this helps!
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sorry I mean they wouldn't have put aortic stenosis in there if they didn't want to gear your answer towards angiodysplasia...
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Quote:
Originally Posted by simba93 View Post
I agree with your reasoning/answer....I have seen this asked in a different way and I have seen the question with angiodysplasia before and they wouldn't have put aortic stenosis in there...the hyperplastic polyps were removed and are a distractor

in addition to that...in the elderly 2 mc causes of rectal bleeds hemorrhoids or diverticulosis...

hemorrhoids can give you painless rectal bleeding and hypotension to the point of syncope...so if there is only bleeding and hypotension and no other information then it will be hemorrhoids....also here the DRE is benign so forget hemorrhoids

diverticulosis gives massive bleeding and LLQ pain and cause hypotension and can cause syncope...here it says NO abdominal pain...so rule out diverticulosis right away...even when I was in surgery and ER both times the elderly presented with abdominal pain

ischemic colitis in addition to that the person will have pain out of proportion...with cardiac history of CABG or Afib, endocarditis, atrial myxoma, intestinal angina (post-prandial) the person will have weight loss and will want to avoid this pain and of course gross blood in the stool

and colonic cancer pt will have bleeding and pencil thin stools and crampy abdominal pain, obstipation because left sided obstruction, right sided will give you bleeding, weight loss, A/N/V

I hope this helps!
Very nice points.Thanks a ton ! Very nice of you to share
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you are very welcome!
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Quote:
Originally Posted by simba93 View Post
diverticulosis gives massive bleeding and LLQ pain and cause hypotension and can cause syncope...here it says NO abdominal pain...so rule out diverticulosis right away...even when I was in surgery and ER both times the elderly presented with abdominal pain
Good one. Only a slight correction.

diverticular bleeding is painless , patients may experience mild abdominal cramping due to the intraluminal blood that triggers spasmodic contraction of the colonic wall.
So, absence of pain does not rule out diverticulosis.
On the other hand, diverticulitis is always accompanied by LLQ pain.
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Umm OK... it is NOT slightly correct...diverticulosis can have has painful or painless rectal bleeding...THAT'S THE WHOLE POINT OF A THOROUGH H/P and especially a physical exam...

In my experience through a surgery rotation + ER and working closely alongside the chairman everyday and doing proper h/p ...I have seen patients present with vague LLQ pain...some people may experience crampy pain or discomfort in the lower abdomen along with bloating, and constipation...


one can make a judgement that it's not diverticulosis based on the stem....if they wanted you to pick that they need to give you information regarding it and gear your answer in that direction...LLQ vague crampy pain...bloating...constipation....

I am speaking for exam sake...in the real world some people present with no pain some people present with sh*t loads of pain that's relative to them....so absence of pain doesn't rule in diverticulosis either...

You are getting sooo technical...I was just trying to give my 2 cents on how to get to an answer with symptoms provided according to the stem for the EXAM....

I am not trying to teach anyone about the details about the disease or what could and could not be in real life...I assume everyone is intelligent enough to go look up the details on their own....anyways I have no idea why you are competing with me since you have so much free time in the world you can teach everyone. goodluck
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Old 09-05-2012
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Quote:
Originally Posted by simba93 View Post
Umm OK... it is NOT slightly correct...diverticulosis can have has painful or painless rectal bleeding...THAT'S THE WHOLE POINT OF A THOROUGH H/P and especially a physical exam...
In my experience through a surgery rotation + ER and working closely alongside the chairman everyday and doing proper h/p ...I have seen patients present with vague LLQ pain...some people may experience crampy pain or discomfort in the lower abdomen along with bloating, and constipation...

one can make a judgement that it's not diverticulosis based on the stem....if they wanted you to pick that they need to give you information regarding it and gear your answer in that direction...LLQ vague crampy pain...bloating...constipation....

I am speaking for exam sake...in the real world some people present with no pain some people present with sh*t loads of pain that's relative to them....so absence of pain doesn't rule in diverticulosis either...
Wow........looks like I somehow managed to hurt someone's ego. You don't like to be criticized even if your are wrong.
I am assuming that you know the difference between diverticulosis and diverticulitis.
If you do, then quote an authentic source of your information. Your "vast" personal experience does not count. For example UW QID 2341 & 2340 which very clearly mentions that diverticulosis presents with painless rectal bleeding. And there can be no better source than UW for the " for exam sake "
Quote:
Originally Posted by simba93 View Post
You are getting sooo technical...I was just trying to give my 2 cents on how to get to an answer with symptoms provided according to the stem for the EXAM....
I am not getting too technical. I am just highlighting the difference between a diverticular bleed and other kind of rectal bleeds.

Quote:
Originally Posted by simba93 View Post
I am not trying to teach anyone about the details about the disease or what could and could not be in real life...I assume everyone is intelligent enough to go look up the details on their own....anyways I have no idea why you are competing with me since you have so much free time in the world you can teach everyone. goodluck
I am not competing with you. There can be no competition between you and me despite your vast surgical experience.
I am just trying to correct whenever I find a mistake. That's the whole point of the discussion.

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Last edited by Novobiocin; 09-05-2012 at 07:24 AM.
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Originally Posted by Novobiocin View Post
Wow........looks like I somehow managed to hurt someone's ego. You don't like to be criticized even if your are wrong.
I am assuming that you know the difference between diverticulosis and diverticulitis.
If you do, then quote an authentic source of your information. Your "vast" personal experience does not count. For example UW QID 2341 & 2340 which very clearly mentions that diverticulosis presents with painless rectal bleeding. And there can be no better source than UW for the " for exam sake "

I am not getting too technical. I am just highlighting the difference between a diverticular bleed and other kind of rectal bleeds.


I am not competing with you. There can be no competition between you and me despite your vast surgical experience.
I am just trying to correct whenever I find a mistake. That's the whole point of the discussion.

Narcissistic personality disorder


hey thanks for the info never knew theses details .....
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