Question of the Week # 373 and 374

373)  A 70 year old woman presents to the emergency room with complaints of abdominal pain for the past one day. The pain is in in lower abdomen and is mild to moderate. It has started suddenly and is persistent. She also reports  having had two episodes of  loose and bloody stools this morning. Her past medical history is significant for coronary artery disease, hypertension and chronic kidney disease. On examination, she is afebrile, blood pressure is 130/80 mm Hg, pulse 90/min and respiratory rate 18/min. Cardiac examination reveals normal and regular heart sounds without murmurs. There is tenderness in the left lower quadrant of the abdomen. There is no rebound tenderness or rigidity. The patient is started on intravenous fluids. Stool studies reveal blood but no leukocytes. Clostridium difficle toxin is negative. Stool cultures are sent. Complete blood count shows White blood cell count at 20,000/µl with left shift. She is started on IV hydration. Which of the following is the most likely diagnosis?

A) Mesenteric Infarction

B) Acute Diverticulitis

C) Acute Mesenteric Ischemia

D) Ischemic Colitis

E) Inflammatory Bowel Disease

374) The patient in the above question undergoes appropriate diagnostic work up and the diagnosis is confirmed. Which of the following is the most appropriate next step in management ?

A) Broad spectrum antibiotics

B) Mesenteric angiography

C) Obtain Surgery Consult

D) Percutaneous Transluminal Angioplasty and Mestenteric stent

E) Start Methylprednisolone and Mesalmaine

13 Responses

  1. C-mesenteric ischemia, B-mesenteric angiography

    • why? What distinguishes acute mesenteric ischemia from other similar presentations like ischemic colitis?

      • I guess ischemic colitis has guarding and rigidity

      • also they will be febrile

      • Abdominal pain out of proportion to physical exam is Mesenteric ischemia.
        I think this is Acute diverticulitis.
        1)LLQ abdominal pain
        2)LLQ tenderness
        3)Fever but in this case afebrile, that makes me confuse
        4)increase WBC count
        But in this case, loose and bloody make me confuse again.

  2. C) Acute Mesenteric Ischemia
    B) Mesenteric angiography

  3. D. Ischemic Colitis and A. broad spectrum antibiotics.
    B/c I think Acute mesentric ischemia pain is like angina , Severe cramps b/c of sudden occlusion of blood supply to mesentery while ischemic colitis can be mild to severe depending upon the inflammation of colon. plus wbc count is increased.

  4. ischemic colitis = broad spectrum Antibiotics
    ischemic colitis = LLQ crampy pain + Overt bloody stool + FOBT
    Acute mesenteric ischemia = Atrial fibrill pt + DIffuse Abd pain +FOBT
    ischemic colitis(75%) is more common than mesenteric ischemia(25%)

  5. D, A because the blood in stool, localization of the pain lower, no hx of cardiac arrhythmia the p exam with tender, the pt is htn and now for him is normal or low bp.

  6. B) acute diverticulitis
    A) broad-spectrum antibiotics

  7. B and A

  8. ischemic colitis = broad spectrum antibiotics ;

    ischemic colitis = LLQ crampy pain + overt bloody stool;
    cause often unknown;but seen in elderly + vascular risk factors;
    > 50 % respond to conservative measures in 48hrs;

    if no response or E/O infarction (peritoneal signs) /sepsis (fever+ hypo tension) go for surgical consult;

    no peritoneal signs = infarction less likely;

    Diverticulitis = fever + h/o low fibre diet are often present & bloody stool less likely in Diverticul – ITIS;

    Acute mesenteric ischemia = A fib pt + Diffuse ABD pain + FOBT again overt bloody stool less likely;

    IBD = ulcerative colitis can present like this but its seen more commonly in young people & absence of fever makes it less likely;

    • very good kishan! excellent

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