A 20-Year-Old Female With Bloody Diarrhoea

A 20-year-old Female with
Bloody Diarrhoea
Presented by
Dr. Samiun Fateeha
Intern Doctor
Shaheed Tajuddin Ahmad Medical College Hospital
Particulars of The
Patient
Name Ms. Joti
Age 20yr
Sex Female
Marital Status Unmarried
Address Bhabanipur, Gazipur
Religion Islam
Occupation Student
Date of Admission 12/10/23
Date of Examination 12/10/23
Chief
Complaints
• Recurrent bouts of loose stool mixed with blood and mucus for 1 month
• Fever and abdominal pain for same duration

History of Present
Illness
According to the statement of patient, she was reasonably well 1 month back. Since
then, she had been suffering from recurrent passage of loose stool, about 4-5 times
daily, often mixed with mucus and fresh blood. Sometimes she complained of only
passage of blood without stool. It was not related to any food, drug or stress.
She also complained abdominal pain for 1 month which was around umbilicus, dull
in nature, mild to moderate in intensity, no radiation, persisting for about half an
hour, not related to food intake, sometimes relieved by defecation. These symptoms
persist for about 5 to 6 days and there was no nocturnal episodes.
History of Present Illness (contd.)
She complained about fever persisting for same duration, not

associated with chills, rigor or night sweat, highest temperature was
101֯ F, relieved by taking paracetamol. She has associated significant
weight loss (4 kgs in 1 month) with loss of appetite, and lethargy.
History of Present Illness (contd.)
There was no history of yellow coloration of skin, sclera and mucous

membrane, vomitus mixed with blood, perianal pain, fecal
incontinence, joint pain, skin rash, eye problem, cough, hemoptysis,
any contact with known case of TB patient, heat intolerance, any neck
or abdominal swelling. Her bladder habit was normal.
History of Past Illness
There is no significant past medical history.

She is normotensive and non diabetic.
Drug
History
• During each hospital admission patient got injectable ciprofloxacin

and metronidazole
• No history of antiplatelet, anti coagulant drugs
• No history of radiotherapy
Family
History
• All her family members are in good health
• No history abdominal malignancy in first degree relatives

Menstrual History
Patient gave history of regular menstruation, persist about 5 days, with

normal flow without any abdominal pain.
Personal
History
She is non smoker.

Socioeconomic
History
She lives in brick-made house, drinks arsenic free tube well water.
Immunization
History
She was immunized as per EPI schedule and took three doses of COVID-
19 vaccination.
General
Examination
• Appearance : Emaciated
• Body Built : Below average
• Co-operation : Co-operative
• Decubitus : On choice
• Anaemia : Moderately anaemic
• Jaundice : Absent
• Cyanosis : Absent
General Examination (contd.)
• Koilonychia : Absent
• Leukonychia : Absent
• Clubbing : Absent
• Edema : Absent
• Neck Veins : Not engorged
• Lymph Nodes : Not palpable
• Thyroid Gland : Not enlarged
General Examination (contd.)
• Bony Tenderness : Absent

• Skin Condition : No pigmentation
• Dehydration : present
• Pulse : 110 beats/min, regular in rhythm
• Blood Pressure : 90/60mmHg (on both arms)
• Respiratory Rate : 22 breaths/min
• Weight : 35 kg (reduced 4 kg over one month)
• Temperature : 99 ֯F
Systemic Examination
Gastrointestinal System
Lips, Gums, Teeth

There is no ulcer or smooth and pale tongue
Gastrointestinal System (contd.)
Inspection
Shape : Scaphoid
Umbilicus : Centrally placed, inverted and vertically slitted
Flanks : Not full
No visible peristalsis, engorged vein or scar mark
Palpation
• Mild tenderness around umbilicus
• Liver and spleen are not palpable
• Kidneys are not ballotable
• Fluid thrill is absent.

Percussion
Shifting dullness is absent.
Auscultation
Bowel sound is present.
Systemic Examination (contd.)
Examinations of the other systems reveal no abnormality.

Salient
Features
Ms. Joti, aged 20yrs, non diabetic, normotensive woman, was admitted to our
hospital with the complaints of recurrent passage of loose stool for 1 month, about
4-5 times daily, often mixed with mucus and fresh blood. Sometimes she
complained of only passage of blood without stool. It was not related to any food,
drug or stress.
She also complained abdominal pain for 1 month which was around umbilicus, dull
in nature, mild to moderate in intensity, no radiation, persisting for about half an
hour, not related to food intake, sometimes relieved by defecation. These
symptoms persist for about 5 to 6 days and there was no nocturnal episodes.
Salient Features (contd.)
She complained about fever persisting for same duration, not

associated with chills, rigor or night sweat, highest temperature was
101֯ F, relieved by taking paracetamol. She has associated significant
weight loss (4 kgs in 1 month) with loss of appetite, and lethargy.
Salient Features (contd.)
On examination, the patient is emaciated, moderately anemic,

dehydrated, hypotensive (BP: 90/60 mmHg), has tachycardia (Pulse:
110bpm) and tachypnoea (Resp. rate: 22 breaths/min) and weighs only
35 kg. There is mild tenderness around umbilicus.
PROVISIONAL DIAGNOSIS?
Ulcerative Colitis
DIFFERENTIAL DIAGNOSES?
• Intestinal TB
• Chron’s disease
• Non specific colitis
• Thyrotoxicosis
INVESTIGATIONS
Complete Blood Count
Date 11.10.23
Hb 11.3 gm/dl
ESR 43 mm in 1st hour
Total count of WBC 14,300/cumm
Neutrophil 72%
Lymphocytes 19%
Total platelet count 3,70,000/cumm
MCV 88.3 fL
MCH 28.7 pg
MCHC 32.5 g/dl
Serum Creatinine 0.7 mg/dl
RBS 6.5 mmol/L
Na – 136 mmol/L
K – 3.8 mmol/L
Serum Electrolytes
Cl – 109 mmol/L
HCO3 – 25 mmol/L
Stool R/M/E, C/S and Occult Blood Test
Date 11.10.23
Mucus +
Blood Present
Protozoa of E. histolytica, E. coli, Giardia lamblia Absent
Cysts of E. histolytica, E.coli, Giardia lamblia Absent
Ova and larva Absent
Pus cell Plenty
Fat globules Absent
Stool for C/S No Growth
Stool of OBT Positive
RBC 12-16/Hpf
CRP Negative
HBsAg Negative
Anti HCV Negative
MT 05 mm In 72 Hrs
Faecal Calprotectin >1000
Serum Albumin <3gm/dl

USG of
W/A
Normal Findings
Plain X ray Abdomen in Erect Posture A/P view
ECG
Colonoscopy with biopsy for histopathology
Multiple erythematous ulcerated continuous lesion

seen from rectum to caecum, bleeds easily on
touch, friable and loss of vascular pattern. Single
polyp present.
Rest of the colon is normal

Comments: Inflammatory Bowel Disease (?UC)
Rectal Polyp
Histopathology Report
Sections show crypt architectural distortion including crypt atrophy,

irregular spacing and size of crypts, crypt shortening, branching alone
with neutrophilic inflammation, cryptitis, crypt abscess, extensive
surface ulceration, erosion with areas of mild nuclear hyperchromasia
and pleomorphism.
No granuloma and malignancy
Diagnosis: severe chronic active colitis histologically suggestive of
ulcerative colitis
Final Diagnosis
Ulcerative Colitis
Treatment
• Rehydration of patient
• Injectable ciprofloxacin, after discharge oral form
• Tab. Mesalazine (400mg)…1+0+0
• Tab. Paracetamol (500mg) ( if temp. >100 F)
• Tab. Tiemonium Methylsulphate

THANK
YOU!

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A 20-year-old Female with

• Fever and abdominal pain for same duration

She complained about fever persisting for same duration, not

There was no history of yellow coloration of skin, sclera and mucous

There is no significant past medical history.

• During each hospital admission patient got injectable ciprofloxacin

• No history of antiplatelet, anti coagulant drugs

• All her family members are in good health

• No history abdominal malignancy in first degree relatives

Patient gave history of regular menstruation, persist about 5 days, with

She is non smoker.

• Bony Tenderness : Absent

Lips, Gums, Teeth

• Mild tenderness around umbilicus

• Liver and spleen are not palpable

• Kidneys are not ballotable

• Fluid thrill is absent.

Examinations of the other systems reveal no abnormality.

She complained about fever persisting for same duration, not

On examination, the patient is emaciated, moderately anemic,

RBS 6.5 mmol/L

Anti HCV Negative

Faecal Calprotectin >1000

Serum Albumin <3gm/dl

Multiple erythematous ulcerated continuous lesion

Rest of the colon is normal

Sections show crypt architectural distortion including crypt atrophy,

• Injectable ciprofloxacin, after discharge oral form

• Tab. Mesalazine (400mg)…1+0+0

• Tab. Paracetamol (500mg) ( if temp. >100 F)

• Tab. Tiemonium Methylsulphate

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