Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine

1. Clinical Correlations The NYU Internal Medicine BlogA Daily Dose of Medicine http://clinicalcorrelations.org

2. Medical Grand RoundsClinical VignetteOctober 8, 2008 Sabina Berezovskaya, M.D.

3. Chief Complaint • 49 year old male presents with early satiety for three months and one day of red blood and clots mixed with stool one week prior to presentation.

4. History of Present Illness • He was in his usual state of health until three months prior to admission when he began experiencing frequent early satiety and subjective weight loss. • One week prior to presentation patient noted bright red blood per rectum with clots which spontaneously resolved after one day. • One day prior to admission, he had routine labs drawn at his cardiology clinic appointment. • He was recalled for admission when his hemoglobin returned significantly decreased from his baseline.

5. Further history • Past Medical History: • GERD • Diabetes Mellitus Type II • Hypercholesterolemia • Hypertension • Coronary artery disease (CAD) with prior STEMI (10/07) requiring percutaneousstenting of the RCA • Past Surgical History: Denies • Social History: • Prior history of alcohol abuse (20 beers per day). Last use 2 years ago • No tobacco or illicit drug use • Family History: Non-contributory • Medications: • Aspirin 81 mg daily • Clopidogrel 75mg daily • Metoprolol 50 mg twice a day • Lisinopril 20 mg daily • Simvastatin 40 mg daily • Metformin 1g twice a day • Pioglitazone 30 mg daily • Esomeprazole 40 mg daily • Allergies: no known drug allergies

6. Physical Exam • General : Well nourished and well developed male; in no acute distress • Vital signs: T- 98º F BP: 99/75 HR: 62 RR: 18 O2 sat: 100% RA • Orthostatics were negative • Abdomen: mildly tender at the right lower quadrant • Rectal: no masses or tenderness; black guaiac + stool The physical exam was otherwise entirely normal.

7. Laboratory Findings • WBC: 7.7, normal differential • Hgb: 7.9 g/dl, MCV 65.6, RDW: 15.8 • Prior baseline hgb 13-14g/dl • Platelets: 384 • Iron: 16 mcg/dL (nl: 42-146) • TIBC: 462 mcg/dL (nl: 250-450) • Ferritin: 4.8 ng/mL (nl: 22-322) • Basic metabolic panel, liver function tests, amylase, lipase & coagulation profile were all within normal limits

8. Imaging • Chest x-ray: no cardiopulmonary disease • EKG: normal sinus rhythm with q waves in II,III, aVF; unchanged from prior baseline.

9. Working diagnosis Lower Gastrointestinal Bleed

10. Colonoscopy • A single sessile polyp measure 6mm in size was found in the hepatic flexure. • The polyp was removed with a hot snare • There was a friable non-obstructing circumferential tumor in the ascending colon immediately distal to the IC valve

11. Colonoscopy

12. Pathologic Diagnosis Poorly Differentiated Invasive Carcinoma + for Cytokeratin 20 and Neuron Specific Enolase (NSE) - for Cytokeratin 7, Synaptophysin or Chromographin

13. Clinical Staging Evaluation • Abdomen & Pelvis CT: Ascending colon tumor with multiple enlarged adjacent mesenteric lymph nodes • Chest CT: No evidence for intrathoracic metastatic disease • CEA <0.5 (nl <=5)

14. Abdominal / Pelvic CT Scan

15. Hospital Course • Patient was transfused with 1 Unit of packed red blood cells and started on Iron supplementation • He remained hemodynamically stable and had no recurrent episodes of bleeding • Patient was evaluated by surgical consult and a right hemicolectomy was scheduled

16. Final Diagnosis Lower Gastrointestinal Bleed due to Poorly Differentiated Adenocarcinoma of the ascending colon and the hepatic flexure