Practice this case based on how you are assessed in your OSCEs, and use the relevant sections for general revision. 🤓
Doctor Instruction:
You are a doctor working in family medicine. Your next patient is a 45-year-old male called Alex Jackson, presenting with constipation. Please take a history and perform an appropriate examination.
Patient History:
45-year-old male, Alex Jackson, a bodybuilder.
In the past few weeks, you have been getting worsening constipation. You are not sure why. You usually eat healthily and avoid junk food. Yesterday, you noticed bright red blood on the toilet tissue paper while trying to wipe yourself, and you saw your stool was coated with fresh blood! You were very shocked because of this. You are not sure if this is yet another flare of your IBD - but you have no tummy pain, and you feel well. Your IBD is usually well controlled with azathioprine. Straining in the toilet can sometimes make your anus slightly sore – you feel like there’s something in your anus, but you are not sure if there's anything. You don’t want to look at your anus or feel around it with your finger – yuck! This grosses you out.
You do have a sensation that your back passage is always full, especially when you strain yourself, and this is starting to affect your ability to work out at the gym. You can sometimes soil yourself by chance – which is embarrassing!
Not sexually active currently. No weight loss. No night sweats. No abdomen pain. No nausea or vomiting. No fever. No SOB. No tiredness. Good energy level.
Ideas, Concerns, Expectations:
You have no idea what this might be; it might be another flare of your IBD. You are, however, worried that you might have cancer because your dad developed bowel cancer and died. You do not want to die so soon! You are still looking for the "one" to marry and happily live with!
Past Medical History:
Ulcerative colitis
Drug History:
Azathioprine.
Allergic to penicillin (anaphylactic reaction)
Family History:
Bowel cancer (father)
Social History:
You work in the gym and often travel to different countries to enter bodybuilding competitions – you have won so many trophies since you were a teenager - you are quite proud of your achievements. You live alone in a flat. You do not smoke or drink. You are generally independent and manage well at home.
Examination Findings:
The abdomen is soft and non-tender. Bowel sound present.
Digital Rectal Examination: non-tender wart-shaped swelling can be felt at the 3 o’clock position proximal to the anal verge – if ask the patient to strain, the swelling becomes visible at the anal verge- appearing bluish, bulging vessels covered with mucosa. No other internal/ external / prolapsed masses can be seen or felt. The prostate gland is normal. Normal anal tone. No PR bleeding or melena.
Differentials:
Haemorrhoid (non-thrombosed)
To rule out Colorectal Cancer
Inflammatory Bowel Disease
Anal Fissures
Diverticulosis
Investigations:
Observations (assess haemodynamic stability and rule out fever)
Proctoscopy to visualise swelling at the rectum
Consider FIT testing if rectal bleeding is not confirmed
Consider Faecal calprotectin – (higher level, more severe IBD)
Consider FBC + iron studies for anaemia (if prolonged PR bleeding + signs of anaemia/infection), CRP (raised in active IBD), baseline bloods: U&Es, LFT, Bone profile, coagulation screen.
Consider Colonoscopy / flexible sigmoidoscopy to exclude other serious pathology and confirm the diagnosis with biopsy i.e. IBD and cancer.
Consider anorectal physiological studies or anorectal US if associated with soiling/incontinence.
Management: