Question

A 26-year-old unmarried woman who comes to the emergency department (ED) complaining of severe left lower quadrant (LLQ) pain and watery bowel movements (BMs) containing bright red blood every 2-3 hours for the past 30 hours. She has a four-year history of inflammatory bowel disease (IBD). She was hospitalized once at the time of diagnosis of the IBD, but has been stable since then and currently doesn’t take any medication. She lives alone and has a significant other, according to whom she is worried about money because she doesn’t get paid when she doesn’t work.

Explain the admission data in terms of the pathophysiology

Admission Data:

BP 102/64

P 110

RR 18

T 100.4

O2 saturation (by pulse oximetry) 98% on room air (RA)

Hemoglobin (Hgb) 9.8  

Hematocrit (Hct) 29

Potassium (K+) 2.8

Sodium (Na) 142

Blood-urea-nitrogen (BUN) 30

Serum creatinine 0.7

Answer 1

In the present scenario,

The chief complaints are: severe left lower quadrant pain (indicates the involvement of left part of colon and rectum.  

Watery bowel movements (Diarrhoea ) with bright red blood ( the frequency of diarrhea is 10-15 times over 30 hrs

These are the characteristic feature of ULCERATIVE COLITIS, a kind of INFLAMMATORY BOWEL DISEASE

PAST HISTORY:

Four year history of IBD and hospitalized for the same

PRECIPITATING FACTORS FOR THE CURRENT EPISODE:

Loneliness and stress associated with income generation

COURSE OF ILLNESS: she had remissions and exacerbations of IBD, after a period of normalcy.

Along with the chief complaints, rest of the data are also suggestive of ulcerative colitis. Hence the admission data can be explained based on the pathology of ulcerative colitis

PATHOLOGY OF ULCERATIVE COLITIS AND COMPARISON WITH ADMISSION DATA OF PATIENT

Irritation and ulceration of superficial mucosa of colon and rectum, leads to bleeding and diarrhoea.

The patient experienced watery diarrhea with blood for about 10-15 times for the past 30 hrs

Since the colon and rectum are involved, the patient experience left lower quadrant pain

In this scenario also, the patient experienced severe left lower quadrant pain

Diarrhea is severe with 10-20 episodes, this leads to dehydration, electrolyte imbalance and increased serum creatinine : BUN ratio

Patient had severe diarrhea. There is an electrolyte imbalance, hypokalemia (S.K+- 2.8meq/l).

There is increased BUN: S. Creatinine for the patient (30:0.7) (normal BUN : Creatinine ratio is 10:1 to 20:1

Most common electrolyte imbalance is hypokalemia ( as K+ absorption takes place in distal colon, severe diarrhea washes out the electrolytes and hinder the reabsorption of nutrients including K+.

Here the patient also had hypokalemia - S.K+ is 2.8 meq/l ( normallly 3.5-5.5 meq/l)

Severe bleeding results in pallor and dehydration, eventually leads to anaemia ( decreased Hb and Hct).

Patient has anaemia, her Hb is 9.8 g/dl (normal 12-15.5g/dl) and Hct is 29 ( normal 35.5-44.5%)

Dehydration leads to tachycardia, hypotension, fever

Patient picture : patient presented with

tachycardia (PR 110/min)

Hypotension (BP 102/64 mm hg)

Fever (temperature 100.4°F)

By concluding, patient is experiencing an acute exacerbation of Ulcerative colitis, a form of inflammatory bowel disease.