Joint Clinico-Pathologic Conference: October 3, 2008

JOINT
CLINICO-
PATHOLOGIC
CONFERENCE
October 3, 2008
DISCUSSANTS: 3 Year rd
ALONZO, Sherylene A.
ATILLO,Roberto Paolo R.
BAGANIA, Shienna Marie D.
BALAGASAY, Karen Jill G.
CINCO, Antonette D.
LIANZON, Celestial C.
DISCUSSANTS: 2 Year nd
AGUIASANDA, Catherine L.
ASUERO, Rose May G.
BULLECER, Schenly Marie I.
CAPAWING,Aimee H.
DEVORA, Maria Rizza D.
DISCUSSANTS: 1 Year st
ALEGRO, Nikko Jake Francis G.

ALMEDA, Laarni G.
ARTECHE, Pinky Prescilla S.
CABONEGRO, Guia Marie P.
CAMULTE, Maridelle R.
Dionaldo, Ivy M.
MODERATOR:
Dr. Juan Mari Isiderio,

FPCS
RESOURCE PERSONS:
Consultants
Department of Surgery
RTR Hospital
PATHOLOGIST:
Dr. Rico P. Lasaca

GENERAL
DATA
• A case of a 20
year old
• Male
CHIEF
COMPLAINT
Acute bleeding
per rectum
HISTORY OF
PRESENT ILLNESS
 A history of acute bleeding per

rectum
 For a period of 2 days
 Appearance of bleeding was dark-
red blood mixed with stool
 No nausea, no vomiting and no
abdominal pain
PHYSICAL EXAM
• Normotensive
• Normothermic
• Had no tachycardia
• Normosthenic
• Not pale
• No peripheral
lymphadenopathy
REVIEW OF SYSTEMS
• No history of
weight loss
CHEST AND
LUNGS:
• No adventitious sound on
respiration
ABDOMEN
• Soft
• non-tender
• no palpable mass
Rectal Exam and
Proctoscopy:
• Maroon-bloody stool
without any evidence
of bleeding point
• ANCILLARY TESTS:
LABORATORY RESULTS
Laboratory Patient’s Normal Interpretation
Values Values
HEMATOCRIT 40 % 38.8-46.4% Normal
WBC 8,000/mm3 5-10x109/L Normal
Differential count
PMN 61 56-65 Normal
LYMPHO 37 25-35 Slightly
Increased
EOSINO 2 2-4 Normal
Blood chemistry
Patient’s Normal Interpretation
values values
Serum 3.4gm/dl 3.5- Slightly

albumin 5.5g/dl decreased
Globulin 4.2gm/dl 2.0- Increased

3.5g/dl
Anti-HIV: non reactive
Hepatitis profile: unremarkable
Coagulogram: within normal limit
CHEST X-RAY:
-unremarkable
ECG:
-unremarkable
Colonoscopy:
• Findings were blood staining along the mucosa
of from rectum to cecum but no ileal blood
staining.
• A small reddish lobulated mass protruding from
the appendiceal opening with blood clot
adherence was noted.
• No ulcer at the cecum and terminal ileum
• No diverticulum, angiodysplasia, hemorrhoids,
nor polyps noted
Course in the ward:
multiple biopsies were

performed at the mass
 bleeding ceased
spontaneously with no further
episode of bleeding
Histopathologic reports:
revealed acute colitis
 no evidence of granuloma,
dysplasias, and malignancy
• Patient was discharge when improved
• repeat colonoscopy for re-biopsy of
the mass was performed 1 month later.
– Still revealed a lobulated mass larger than
the previous with congestion protruding
from the appendiceal opening.
– Few new clean based ulcers on the
terminal ileum and another one on the ileo
cecal valve
– intervening mucosa was univolved
– No deformity of ileo-cecal valve and
cecum were found
• Multiple biopsies were again performed
• Revealed focal active colitis

• no evidence of granuloma, dysplasia, and
malignancy
• Patient was re admitted for a procedure.

• Impression from the :
Consultants
Residents
Senior interns
Junior clerks
Group 2
Group 3
Group 4
ANATOMY
Gastrointestinal system
Gastrointestinal system
The lower GI tract comprises the intestines and anus.
Bowel or intestine
Small intestine, which has three parts:

Duodenum
Jejunum
Ileum
Large intestine, which has three parts:

Cecum (the vermiform appendix is attached to the
cecum).
Colon (ascending colon, transverse colon,
descending colon and sigmoid flexure)
Rectum
Anus
Blood supply
From Superior mesenteric Inferior mesenteric artery
artery(right side of the (left side of the colon)
colon)
• Ileocolic artery • Colic artery
• Ileal branch
• Sigmoid artery
• Ant. And Post. Cecal
branches • Rectal arteries
• Appendicular artery (superior,middle and inferior)
Lower gastrointestinal tract
Size and location
• The appendix averages 10 cm in length, but can range from 2 to 20 cm.
The diameter of the appendix is usually between 7 and 8 mm. The longest
appendix ever removed measured 26 cm in . in the lower right quadrant of
the abdomen, or more specifically, the right iliac fossa. Its position within
the abdomen corresponds to a point on the surface known as
McBurney's point . While the base of the appendix is at a fairly constant
location, 2 cm below the ileocaecal valve, the location of the tip of the
appendix can vary from being retrocaecal (74%) to being in the pelvis to
being extraperitoneal. In rare individuals with situs inversus, the appendix
may be located in the lower left side.
Function
• Given the appendix's propensity to cause death via infection, and the
general good health of people who have had their appendix removed, the
purpose of the appendix has mystified scientists for some time. There have
been cases of people who have been found, usually on laparoscopy or
laparotomy, to have a congenital absence of an appendix. There have
been no reports of impaired immune or gastrointestinal function in these
people.
IMPRESSION
CROHN’S DISEASE
Salient features
• 20 years old
• Acute bleeding per rectum for 2 days
• Lymphocyte 37
• Globulin 4.2 gm/dl
• No granuloma
• Small reddish lobulated mass
• No deformity in the ileo-cecal valve
• Few new superficial clean-based ulcers on the
terminal ileum
DIFFERENTIAL
DIAGNOSIS
Differential Diagnosis:
INFECTIOUS
INFLAMMATORY
LOWER GI BLEEDING
NEOPLASTIC VASCULAR
INFECTIOUS
INFECTIOUS DYSENTERY
(Campylobacter, E. coli, Shigella, Salmonella, Protozoal
Infections)
R/I: bloody stool
R/O: increased eosinophil
INTESTINAL TUBERCULOSIS
R/I: lobulated mass, ulcerations
in terminal ileum and ileocecal
valve, lymphocytosis
R/O: no granuloma,no significant

x- ray findings
VASCULAR
ISCHEMIC BOWEL DISEASE
R/I:bleeding
R/O:occur in older individual

NEOPLASM
COLORECTAL CANCER
R/I: mass, ulcerative, bleeding
R/O: malignant,with dysplasia
APPENDICEAL CARCINOID
R/I: usually asymptomatic,small mass
R/O:median age of 40 years old and elderly, malignant, with

dysplasia
INFLAMMATORY
ULCERATIVE COLITIS
R/I: ulceration through the mucosa, bleeding, no
granulation, onset of disease peak at
20-25 years old
R/O: decreased albumin, continuous lesion frequently located

left side, mainly rectum, does not involve any other
organ, with dysplasia, may progress to frank
carcinoma
PATHOPHYSIOLOGY
 Infectious, immunologic, genetic and
environment
Activation of resting macrophages
Release of cytokine, cause differentiation

of lymphocytes(Th1)
Stimulation of body’s defense system

(“turning on of immune system”)
Unable to shut activation of it’s immune system
Exuberant inflammatory response
Small reddish ulceration of underlying mucosa and involving

lobulated mass also the terminal ileum and ileo-cecal valve
bleeding
Blood mixed with fecal material is

seeded thru peristaltic movement
Blood staining along the mucosa from

rectum to cecum
DIAGNOSTIC
PROCEDURE
Ileocecal Resection
TREATMENT
• Mild to moderate disease: This category includes ambulatory patients
who tolerate oral intake and have no signs of toxicity, tenderness,
mass, or obstruction. 5‑Aminosalicylic acid (5‑ASA, mesalamine ) is
commonly used as first-line treatment, although its benefits for small-
bowel disease are modest at best. Pentasa is the most effective
formulation for disease proximal to the terminal ileum; Asacol is
effective in distal ileal disease; all formulations are roughly equivalent
for Crohn's colitis, although none of the newer preparations rival
sulfasalazine.
• For efficacy on a dose-for-dose basis.
• Antibiotics are considered a first-line agent by some clinicians, or they

may be reserved for patients not responding to 4 wk of 5‑ASA; their
use is strictly empiric. With any of these drugs, 8 to 16 wk of treatment
may be required.
• Glucocorticoids (Prednisone) if unresponsive to 5-ASA theraphy.

FINAL DIAGNOSIS:
LOWER
GASTROINTESTINAL
BLEEDING PROBABLY 20
TO CROHN’S DISEASE
(ileocolitis)

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JOINT

ALEGRO, Nikko Jake Francis G.

Dr. Juan Mari Isiderio,

Dr. Rico P. Lasaca

 A history of acute bleeding per

Serum 3.4gm/dl 3.5- Slightly

Globulin 4.2gm/dl 2.0- Increased

multiple biopsies were

• Revealed focal active colitis

• Patient was re admitted for a procedure.

Small intestine, which has three parts:

Large intestine, which has three parts:

(Campylobacter, E. coli, Shigella, Salmonella, Protozoal

R/O: no granuloma,no significant

ISCHEMIC BOWEL DISEASE

R/O:occur in older individual

R/O:median age of 40 years old and elderly, malignant, with

R/O: decreased albumin, continuous lesion frequently located

Activation of resting macrophages

Release of cytokine, cause differentiation

Stimulation of body’s defense system

Unable to shut activation of it’s immune system

Exuberant inflammatory response

Small reddish ulceration of underlying mucosa and involving

Blood mixed with fecal material is

Blood staining along the mucosa from

• For efficacy on a dose-for-dose basis.

• Antibiotics are considered a first-line agent by some clinicians, or they

• Glucocorticoids (Prednisone) if unresponsive to 5-ASA theraphy.

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