CLINICAL PATHOLOGICAL CONFERENCE
Baylor College of Medicine
Room M-112 DeBakey Building
November 7, 2002
12:15 - 1:15 P.M.

Clinical Discussant: Ernest E. Bartimmo, M.D.
Pathologist: Chris Finch, M.D.
Case Preparation: Robyn Fader, M.D.

Chief Complaint: Diarrhea and weight loss.

The patient is a 47 year old Caucasian female with no previous medical problems who developed diarrhea in December 2001. She described her bowel movements initially as soft and brown without blood, which she attributed to an "upset stomach from stress". She had approximately 3 bowel movements every 6 hours. After one month of frequent bowel movements, she went to her physician for evaluation and was told to take Imodium. She took Imodium and Pepto Bismol without much relief, and the diarrhea progressively worsened over the next 8 months. The bowel movements became more frequent and smaller in volume which she describes as liquid brown with mucous and a fibrous component. Associated symptoms include dull crampy bilateral lower abdominal pain without radiation, which is made worse with movement and eating and relieved ten minutes after a bowel movement. She also reports tenesmus and an incomplete feeling of emptying. She denies having frank blood in the stool, but after having many bowel movements, she notices a small amount of blood on the toilet paper. She states that drinking a sip of water or one bite of food causes an urge to defecate. She has been unable to work as a waitress for two months because she has frequent episodes of fecal incontinence.

Two months prior to admission, she developed a rash described as pruritic, erythematous papules over her torso and upper arms in a photosensitive distribution. A biopsy revealed granuloma annulare and resolved spontaneously over a month.

For several weeks prior to admission, the patient has had the urge to defecate every 15 minutes, reporting having 50 small volume brown liquid stools a day. Her symptoms do not change with fasting and persist at night causing her to wake up every half hour to go to the bathroom. Given the severity of her symptoms, she came to Ben Taub for evaluation.

Medical History: Migraines (3 episodes a year). No history of diabetes, hypertension, liver or renal disease. G1 P1, last menstrual period one month prior to admission

Surgical History: Tonsillectomy, appendectomy, left knee arthroscopy

Medications: Imodium and pepto bismol do not help much with her symptoms, Imitrex prn migraine

Review of systems: She reports having a 60 pound unintentional weight loss over 8 months, generalized weakness, anorexia, and cold intolerance. She notes dizziness on standing for 3 weeks. She has occasional nausea but no vomiting or jaundice. She denies having fever, night sweats or joint pains. She denies genitourinary or cardiopulmonary symptoms.

Allergies: No known drug allergies.

Family History: Her mother died at age 50 with coronary artery disease and diabetes mellitus. Her father died at age 57 with esophageal cancer. One brother alive and well.

Social History: The patient has been married for 5 years and has been in a monogamous relationship for 10 years. She works as a waitress. She drinks 3 beers a day for 20 years, no tobacco, no illicit drug use.

Physical Exam:
Supine BP 112/55 Pulse 100 Respirations 14 Temp 99.0
Sitting BP 95/50 Pulse 105 Weight 140 pounds Height 5' 4"
Standing BP 90/50 Pulse 115

General: She is alert but appears weak and ill
HEENT: PERRL, oropharynx dry without lesions, pale conjunctivae
Neck: Supple, no lymphadenopathy, no thyroid enlargement, mass or bruit
Lungs: Clear to auscultation and percussion
Cardiovascular: Tachycardic regular S1 and S2, No murmurs, rubs, gallops
Abdomen: Soft, nondistended, no guarding or rebound, bilateral lower abdominal tenderness is present with deep palpation, no hepatosplenomegaly
Rectal: External hemorrhoids, normal sphincter tone, no fissures or masses
GUAIAC POSITIVE BROWN LIQUID STOOL
Pelvic: Normal external genitalia, no vaginal discharge. Bimanual: no cervical motion tenderness, no masses palpated
Extremities: No cyanosis, clubbing or edema, pulses symmetric
Skin: No rash
Neurologic: Alert and fully oriented, no focal deficits

The patient was admitted and the following lab studies were obtained (see Flow Sheet). A diagnostic procedure was performed.