Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are currently a doctor working in the emergency department. Your next patient is a 51-year-old gentleman called Isaac Newton, presenting with bloody stool. Please take a history and perform an appropriate examination.
Patient History:
Your name is Isaac Newton – a 51-year-old – estate agent.
In the past three days, you have been having maroon-red diarrhoea with clots (not bright red or dark black, smelly stools). This is not settling or getting worse. You don't think you have eaten anything abnormally lately, but you generally eat a low-fibre diet. You did have some constipation a few days before having diarrhoea. You haven't noticed any lumps or bumps around your tummy. You have lost your appetite. Feeling sick and have been vomiting slightly (just food contact / no blood or bile). You also noticed aching pain on your tummy's lower left side. It comes on intermittently. Worsen by eating and improved slightly by emptying stool and passing gas. You feel your tummy is a little more bloated than usual. You also noticed you had been feeling warm with a bit of shivering last night. You do feel tired lately, but you are not sure whether this is from your stressful work or lack of sleep. You are not sure if you have lost any weight recently. Waterworks normal.
Ideas, Concerns, Expectations:
You have no idea what this might be. You hope it is not cancer – you have much more to live for! You are concerned because the stool is red; you might be bleeding somewhere in your bowels. You really want to know what is happening- your wife is concerned about this.
Past Medical History:
Ankylosing spondylitis, atrial fibrillation, diverticular disease, obesity, hypercholesterolaemia
Drug History:
Ibuprofen, apixaban, lansoprazole
Allergic to shellfish (rash)
Family History:
Ulcerative Colitis
Social History:
Ex-smoker – used to smoke 10 cigarettes a day for 10 years.
Drink a bottle of wine every other week.
Work as an estate agent.
Live with wife.
Examination Findings:
Lower left quadrant pain tenderness
No guarding or signs of peritonitis
No rebound tenderness
No hernia/ lump
No signs of testicular torsion
Bowel sound present
Murphy's sign negative
Rovsing's sign negative
PR exam – may show tenderness or mass suggesting pelvic abscess.
Differentials:
Diverticulitis +/- complications
IBD
Ischaemic colitis
Gastroenteritis
To rule out GI cancer
Other causes of abdominal pain to rule e.g. peptic ulcers (use of NSAIDs + apixaban)
Investigations:
Bedside:
Observations (pyrexia/ tachycardia)
ECG (tachycardia/rule out arrhythmias) +/- echo (cause of embolism/ valvular pathology)
Urine dip (rule out UTI as a cause of abdominal pain)
Bloods:
CRP/WCC (raised in diverticulitis)
Hb (blood loss- anaemia)
Lactate (raised in ischaemic colitis)
U&Es (baseline + urea raised in dehydration/GI bleeding)
CRP
Group and Save
Coagulation Screen (bleeding + ischaemia?)
Blood Culture if suspected infection/sepsis
LFT/Amylase (rule out abdominal pain causes)
Imaging:
XR Abdomen ( to look for dilated bowel loops, thumbprinting in ischaemic colitis…etc.)
Erect CXR (to rule out air under the diaphragm)
Urgent CT scan with contrast (aim with 24 hours) for suspected complicated diverticulitis + high CRP (alternative non-contrast CT, MRI, US)
Consider CT angiography for suspected bowel ischaemia (gold standard)
Special Test:
Colonoscopy (to confirm diagnosis/ rule out other possible diagnoses)
Flexible sigmoidoscopy (to rule rectosigmoid lesion)
If no bleeding source can be identified with sigmoidoscopy, consider a non-invasive approach e.g. (nuclear scintigraphy) or an invasive approach e.g. angiography/ colonoscopy to localise/treat the bleeding source.
Consider cystoscopy/ cystography, contrast radiographs or methylthionium chloride (methylene blue) studies for colovesciular fistula tracts.
Management: