Patient : Mrs. C
Age : 74 years old
History of Presenting Complaint
Mrs. C was seen at the surgery on 03/09/09 complaining of changes in bowel habits. She noticed her bowel habits had become more erratic over the last few months, where she had episodes of diarrhoea alternating with constipation. In the past, she used to have problems with chronic constipation. She also noticed bright red blood in her stools which normally came towards the end of defeacation. There was no mucus in her stools, malaena, pain noted on defeacation. She complained of left iliac fossa pain which came intermittently and mostly relieved upon defeacation. Despite having tenesmus and increasingly aware of passing flatus, there was no faecal incontinence. She agreed that her haemorrhoids had become more problematic recently. But, did not notice any peri-anal ulceration.
She denied any weight loss, changes in appetite, indigestion, heartburn, haematemesis or nausea/ vomiting. She did not complain of urinary symptoms (e.g. dysuria, haematuria, frequency, urgency, incontinence, etc).
She had some problems with stiff joints mainly in her wrists, hands, knees and ankles, which were worse in the morning. She has a history of rheumatoid arthritis. Occasionally, her joints would flare up and become swollen, erythematous and painful. At present, she did not complain of any joint problems as the anti-rheumatoid medications and analgesics provided symptomatic relief and remission of her RA. However, the co-codamol does not help with her constipation.
Past Medical History
- Chronic constipation
- Dupuytren’s disease and thickening of Archilles tendon
No significant family history.
Lives with her family. Does not smoke. Drinks occasionally.
None to note.
None to note.
None to note.
None to note. No dysuria, polyuria or haematuria.
None to note. No fevers or rigors
None to note. No polydipsia or polyuria.
No sexual dysfunction.
RELEVANT PHYSICAL EXAMINATION
- Not distressed
- Alert and not-lethargic
- Not breathless
- Not cushingoid
Hands and nails
No jaundice/ skin-pallor
No generalised skin pigmentation of haemosiderin
No palmar erythema / Non-pallor palmar creases
Presence of dupuytren’s contracture on both hands
No finger clubbing, leuconychia, koilonychia
Non jaundiced eyes
No Kayser-Fleischer rings (brownish green rings)
Presence of corneal arcus
Good oral hygiene
No glossitis or angular stomatitis or ulceration
No spider naevi
No scars but striae present
No visible engorged veins or visible peristalsis or arterial pulsation
No caput medusae/ No Cullen’s (blue discolouration of umbilicus)/ No Grey-Turner’s sign (blue discolouration of flank)
Symmetrical movement of the abdomen with respiration
No enlarged supraclavicular lymph node
No tenderness/ guarding
No abnormal masses or organomegaly
Soft, regular liver edge, not enlarged or tender, non-pulsatile
Normal liver span (<13 cm)
No dullness on complete expiration (no splenomegaly)
Absence of shifting dullness (no ascites)
Bowel sounds increased
PR examination was not done. However, would expect to find piles if PR was performed.
Summary of problems
Mrs. C presented with chief complaint of alternating bowel habits, bright red blood in stools and increasing awareness of passing flatus. It is important to rule out the more sinister colorectal carcinoma especially in the older aged group patients like Mrs. C and particularly when she had been having chronic constipation in the past. It was encouraging that she did not have any weight loss and changes in her appetite.
*The most likely differential for Mrs. C’s case is bolded.
Differentials of change in bowel habits:-
Change in diet – low fibre/ decreased fluid intake
Inflammatory bowel disease (Crohn’s/ ulcerative colitis)
Irritable bowel syndrome
Constipating drugs – opiods, antihypertensives, aluminium alkali
Neurological – cerebral or spinal cord lesion e.g. post-stroke (abnormal sphincter tone/ anal sensation (unlikely in Mrs. C’s case)
Differentials of passage of blood per rectum:-
Bleeding haemorrhoids (bright red commonly, soiling pan following defeacation)
Inflammatory bowel disease
Massive upper GI bleed
Ischaemic colitis, infectious colitis, angiodysplasia
Recent Investigation and Results:
Sigmoidoscopy (done on 11/08/09)
Sigmoid diverticulosis at (a)
Mrs. C was found to have diverticular disease on sigmoidoscopy which was done last month. Her PR bleed is highly likely due to her haemorrhoids. Giving her a compound haemorrhoidal preparation containing corticosteroids and LA would hopefully help to relieve her symptomatic haemorrhoids.
If the piles do not improve, it may be an option to consider rubber band ligation, infra-red coagulation, sclerosants, cryotherapy or haemorrhoidectomy if the piles become persistently prolapsed.
To address her alternating diarrhoea and constipation would be difficult especially when she has diverticulosis. It takes time for the patient to adjust to the right dose of laxative combined with diet modification.
Reflective Commentary: Diverticular disease (DD)
A diverticulum is defined as an outpouching of the bowel wall. Diverticulosis is when diverticula are present and diverticular disease is when diverticula is symptomatic. Diverticulitis happens when the diverticulum is inflamed. Diverticula may either be congenital or acquired and can arise in any part of the bowel. Commonly, they occur in the colon in patients over 50 years old. They are frequently found in the sigmoid and descending colon. Passing from left to right side of colon, they reduce in occurrence.
DD is associated with low fibre diet. Diets low in fibre usually do not distend the colon, allowing high pressure in the lumen to develop resulting in outpouching at site of weakness.
Diverticulitis occurs when the neck of the diverticulum becomes obstructed.  This can lead to perforation into:- 
1) general peritoneal cavity to cause generalized peritonitis
2) the pericolic tissues with formation of pericolic abscess
3) adjacent structures (e.g. bladder, small bowel, vagina) forming a fistula.
Signs and symptoms
In 95% of cases, diverticulosis is asymptomatic in 95%. No treatment other than dietary advice is indicated in these patients.
Known as “left-sided appendicitis”  – acute onset of low central abdominal pain, which shifts to LIF
Fever + tachycardia
Local tenderness and guarding
Vague mass in LIF and also on rectal exam
Perforation into peritoneal cavity causes peritonitic abdomen (rigid board like)
Pericolic abscess may mimic appendix abscess but on left side – a tender mass + swinging fever + leucocytosis
Chronic Diverticular Disease
Presents with erratic bowel habits and intermittent LIF pain. It may also mimic features of colorectal CA:- 
Large bowel obstruction or small bowel obstruction.
Blood and mucus per rectum – episodes of severe pain in LIF, passage of mucus/ bright red blood/ maleana/ anaemia due to chronic occult blood loss.
Thickened mass in sigmoid colon felt per rectum.
How this case relates to the GMC themes in ‘Tomorrow’s Doctors’:
Theme 2: Treatment
Blood test – neutrophilia, raised ESR/CRP.
USS – thickened bowel and large pericolic collections, but less sensitive than CT.
Spiral CT of lower abdomen – gives additional information about colonic wall thickening, fistula formation,etc.
Mild attacks can be managed at home with bowel rest (fluids only) + antibiotics.
If oral fluids/ pain cannot be tolerated, admit to hospital for analgesia, NBM, fluids, antibiotics (cefuroxime + metronidazole until culture results available).
General peritonitis – manage as an acute abdomen. At lapartomy, Hartmann’s procedure may be done.
Pericolic abscess – initially this can be treated conservatively similar to appendix abscess. But if enlarging, drainage is often required.
Chronic diverticular disease
If symptoms are mild, conservative treatment is often preferred. Bowels should be regulated by lubricant laxative and high fibre diet. If symptoms are severe or if carcinoma cannot be excluded, laparotomy and resection of the sigmoid colon is indicated.
Mrs. C’s diverticular disease is producing mild to moderate symptoms of erratic bowel habits and probable occasional bleeds which is hard to determine for certainty as she has ongoing haemorrhoids trouble. It is important to recheck her haemoglobin levels from time to time to ensure that she is not having long-term occult bleed. If her problems of erratic bowel habits and PR bleed persist, it is important to perform more detailed investigations (e.g. colonoscopy / CT of lower abdomen) to rule out any possibility of colorectal CA which may co-exist with diverticular disease. This may mean a laparotomy with sigmoidectomy if the condition aggravates.
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