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PILYA
OBJECTIVES
To determine the cause of recurrent
diarrhea in a 49 y.o. male
To discuss the diagnostic approach on
patient presenting with this condition
To discuss management done on this case
IDENTIFYING DATA
J.M.
49 y.o.
Male
Catholic
Filipino
Caloocan City
CHIEF COMPLAINT
HEMATOCHEZIA
VIDEO GASTROSCOPY
Erosive Gastritis, Antrum: Gastric Ulcer,
Antrum, Forrest 3
VIDEO COLONOSCOPY
Non-Specifi c Pancolitis
WBC
01/28/20
15
8.3
0.62
06/26/20
15
8.1
0.59
07/16/20
15
13.7
0.69
0.18
0.27
0.14
0.10
0.08
0.12
0.10
0.05
0.05
Neutroph
ils
Lymphoc
ytes
Monocyte
s
Admissiom
MEDICAL HISTORY
Patient claims to be non-hypertensive
and diabetic. He denies any history of
allergies to drugs and foods
FAMILY HISTORY
- Hypetension
- DM
- Malignancy
- Bronchial Asthma
PERSONAL HISTORY
Denies smoking and ilicit drug use but
occasionally drinks alcoholic beverages
Non-promiscuous
REVIEW OF SYSTEM
General: (+) weight loss, (-) chills, (+)
malaise
Skin: (-) rash (-) discoloration, (-) pallor (-)
cyanosis
HEENT: (-) epistaxis (-) colds
Respiratory: (-) cough, (-) hemoptysis
CVS: (-) Chest pain (-) palpitations (-) PND
REVIEW OF SYSTEM
PHYSICAL EXAMINATION
Vital signs:
BP = 170/90mmHg (sitting)
CR = 89 BPM RR = 19 T = 36.7C
Weight = 69 Kg
Height = 54
BMI = 26.3 (Obese)
ADMITTING IMPRESSION
Lower Gastrointestinal
Bleeding secondary to Amebic
Colitis
Rule out Inflammatory Bowel
Disease and Colorectal CA
ON ADMISSION
IVF: PNSS 1L x KVO
Low salt, low fat die
Diagnostics
CBC
Urinalysis
Fecalysis
Serum electrolytes, Crea
SGPT
Medications
1) Pantoprazole 40 mg IV
2) Racecadotril 100 mg cap, 1 cap
OD
DAY 1 OF ADMISSION
S
Problem:
VS:
BP 160/90
HR 89
RR 19
Temp. 36.7
CBC presence
of eosinophilia
Resume Salofalk
granules 1.5 gm
TID
Hematochezi
a
Diarrhea
Abdominal
pain
Unremarkable
Physical
Examination
Fecalysis: No
ova or parasite
seen
Rule out
Amoebic Colitis
T/C Eosinophilic
Colitis
Start Prednisone
5 mg tab, 1 tab
TID
Results
(08/04/16)
10,2
Results
(08/06/16)
9.1
Neutrophils
0.69
0.60
5.00-10.00
10^9/L
0.40-0.60
Lymphocytes
0.16
0.26
0.20-0.40
Monocytes
0.11
0.10
0.02-0.08
Eosinophils
0.04
0.04
0.01-0.03
Basophils
0.00
0.00
0.00-0.02
Hgb
140
135
123.00-152 g/L
Hct
0.42
0.41
0.37-0.42
Platelet
411
409
150.00-450.00
WBC
Normal values
FECALYSIS
Color
Dark Red
Consistency
Watery
WBC
None seen
RBC
TNTC
Fat Globules
None seen
Yeast Cells
None seen
Ova/Parasite
No Ova or
Intestinal Parasite
Seen
Occult Blood
Positiv
URINALYSIS
Color
Transparency
RBC
Pus Cells
Bacteria
Epithelial Cells
Light Yellow
Slightly turbid
0-2/HPF
0-2/HPF
Few
Few
Creatinine
BUN
Potassium
Sodium
Chloride
SGPT
8/4/2016
Normal
68.20 umol/L Values
45.00-84.00
mmol/L
2.60 mmol/L
2.14-7.14
mmol/L
3.56 mmol/L
3.30-5.10
mmol/L
141.00
136.00-145.00
mmol/L
mmol/L
101.80
98.00-107.00
mmol/L
mmol/L
27.50 U/L
0.00-41.00 U/L
Result
ESR
21 mm/hr
Problem:
1. Hematoch
ezia x1
episode
2. Less
abdominal
pain
VS:
BP 140/80
HR
RR
Temp.
Eosinophilic
Colitis
Continue with
present
medications
No rashes
No signs of
dehydration
Abdomen:
soft,
NABS,nontender
Hypertension
controlled
No episode of
hematochezia
VS:
BP 130/80
Eosinophilic
Colitis
No abdominal
pain
No rashes
Hypertension
controlled
Refer to
dietician
regarding
hypoallergenic
diet
No signs of
dehydration
Abdomen:
soft,
NABS,nontender
No subjective
complaints
VS:
BP 130/80
HR 76
RR 18
Temp. 36.8
Eosinophilic
Colitis
For discharge
Home meds
1. Salofalk
granules 1.5
gm, BID
2. Prednisone
5 mg tab, 1
tab TID after
meals
3. Omeprazole
40mg tab, 1
tab OD
Follow up after 2
weeks with
repeat CBC,
SGPT, SGOT,
Crea, ESR and
fecalysis
No rashes
No signs of
dehydration
Abdomen:
soft,
NABS,nontender
Hypertension
controlled
FINAL DIAGNOSIS
Eosinophilic Colitis
FOLLOW UP
S
No subjective
complaints
Unremarkable
Eosinophilic
Colitis,
improved
clinically with
steriod
Continue
prednisone on
tapering
dosages
No recurrence
of diarrhea
and
hematochezia
Hypertension
controlled
DISCUSSION
Eosinophilic
Gastrointestinal
Disease
INTRODUCTION
Disorders that selectively affect
GI tract
Eosinophil-rich inflammation in the
absence of known causes for
eosinophilia
EOSINOPHIL BACKGROUND
constitute 13% of the granulocyte pool
absolute eosinophil count of ,350 per
ml
Following a brief half-life of 812 h,
eosinophils traffi c to specifi c tissues,
particularly the gastrointestinal tract,
where they reside for at least a week
Eosinophil function can be benefi cial or
detrimental
Triggering of eosinophils by
engagement of receptors for cytokines,
immunoglobulins, and complement can
lead to the generation of a wide range
of infl ammatory cytokines
Yousefi S, Gold JA, Andina N, Lee JJ, Kelly AM, Kozlowski E, et al. Catapult-like release of
mitochondrial DNA by eosinophils contributes to antibacterial defense. Nature
ETIOLOGY
A non- IgEassociated disease
Some studies point to a T lymphocyte
mediated process.
Exact immunologic mechanisms
responsible for this condition have not
been identifi ed.
Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of allergy and
clinical immunology. 2004;113(1):11-28.
CLINICAL PRESENTATION
Present with a constellation of
symptoms that are related to the
degree and area of the GI tract
aff ected
1. Mucosal layer
2. Muscularis layer
3. Serosal layer
CLINICAL PRESENTATION
Mucosal disease
Vomiting
Abdominal pain
Diarrhea
Blood loss in stools
Iron defi ciency anemia
Malabsorption
Protein-losing enteropathy
Failure to thrive
Chehade M, Magid MS, Mofidi S, Nowak-Wegrzyn A, Sampson HA, Sicherer SH. Allergic
eosinophilic gastroenteritis with protein-losing enteropathy: intestinal pathology, clinical
course, and long-term follow-up. Journal of pediatric gastroenterology and nutrition.
CLINICAL PRESENTATION
Muscle layer disease
Bowel wall thickening & Intestinal
obstruction
Cramping & abdominal pain
associated with nausea and vomiting
Ingle SB, Hinge Ingle CR. Eosinophilic gastroenteritis: an unusual type of gastroenteritis.
World journal of gastroenterology : WJG. 2013;19(31):5061-6.
CLINICAL PRESENTATION
Subserosal disease
Eosinophilic exudate ascites
Abundant peripheral eosinophilia
Serosal and visceral peritoneal
infl ammation leads to leakage of fl uids
Ingle SB, Hinge Ingle CR. Eosinophilic gastroenteritis: an unusual type of gastroenteritis.
World journal of gastroenterology : WJG. 2013;19(31):5061-6.
DIFFERENTIAL DIAGNOSIS OF EC
DIAGNOSTIC EVALUATION
No single test is the gold
standard for diagnosis
Peripheral blood eosinophilia or
eosinophils in the stool suggests
eosinophilic colitis.
Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of allergy and
clinical immunology. 2004;113(1):11-28.
Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of allergy and
clinical immunology. 2004;113(1):11-28.
Rothenberg ME. Eosinophilic gastrointestinal disorders (EGID). The Journal of allergy and
clinical immunology. 2004;113(1):11-28.
TREATMENT
Eosinophilic colitis of older
: Cromoglycate
,Montelukast,Histamine receptor
antagonists : generally unsuccessful
:Aminosalicylates and systemic or
topical glucocorticoids :typically
used and appear to be effi cacious
:Azathioprine or 6-mercaptopurine:
in severe cases
Prednisone is
tapered over the
next 2 or more
weeks
One to 2 months after the
prednisone has been
stopped
Budesonide dose is slowly
tapered over an additional
2 to 4 months to the
minimum required dose.
clinical
symptoms
are
controlled
clinical
symptoms
are
controlled
clinical
symptoms
are
controlled
clinical
symptoms
are
controlled
Prednisone is
tapered over the
next 2 or more
weeks