2 | Abdominal Key

History

A 27-year-old Chinese gentleman with previous good health presents to a private physician with a 6-month history of cramping abdominal discomfort, diarrhoea up to 5-6 times per day and rectal bleeding. This is associated with weight loss of around 3-4kg over the past 6 months. He is a non-smoker and non-drinker. There is no family history of colorectal cancer or inflammatory bowel disease. He has no significant travel history. There are no recent significant life stressors.

Physical examination

•Afebrile, pulse 74 bpm, BP 110/60mmHg, SaO₂ 98% on RA.

•Appears well.

•Examination of the hands reveals no clubbing and normal-appearing palmar creases.

•Head and neck examination is unremarkable.

•Cardiovascular: HS dual, no murmur.

•His chest is clear on auscultation.

•Abdominal examination reveals a soft abdomen, with no focal tenderness and no organomegaly.

•No signs of oedema.

Investigations

•CBC:

–WBC 8.3 x 10⁹/L;

–haemoglobin 12.3g/dL (microcytic hypochromic picture);

–platelets 255 x 10⁹/L.

•ESR 31mm/hr.

•CRP 32mg/L.

What is your differential diagnosis?

The differential diagnosis includes inflammatory bowel disease and infectious colitis.

What other blood tests would you order?

•Liver and renal function tests

•Bone profile.

All are within normal limits.

What do these laboratory data suggest?

The blood work is highly suggestive of an active inflammatory process.

What other tests would you order?

An oesophagogastroduodenoscopy (OGD) and a colonoscopy are arranged.

Colonoscopic findings show multiple irregular ulcers at the transverse colon, descending colon, sigmoid colon and upper rectum. There is also terminal ileum ulceration.

Multiple biopsies are taken which show granulomatous inflammation but no acid-fast bacilli on Ziehl-Neelsen stain. No Mycobacterium tuberculosis polymerase chain reaction (MTB-PCR) had been performed by the previous referring hospital.

Oesophagogastroduodenoscopy shows gastritis only.

What imaging test would you order?

A CT of the abdomen and pelvis with contrast (Figure 2.1).