Rectal Bleeding in a 47-Year-Old Farmer Who Can't Pass Flatus

Sarah El-Nakeep, MD


September 12, 2022

Editor's Note:
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A 47-year-old man presents to the emergency department with a 1-day history of severe abdominal pain. He cannot pass stool or flatus. For the past 2 weeks, he has had a fever (temperature of 102.2 °F [39 °C]), which is accompanied by rigors and chills and is reduced by antipyretics. The fever is also associated with fatigue, headache, and body aches. A 1-week course of ciprofloxacin and metronidazole failed to resolve the fever.

In addition, for the past week, the patient has had episodes of rectal bleeding that involve fresh red blood. He reports a mild, dry cough but no expectoration, dysuria, vomiting, or diarrhea. During the past 3 months, he has had a weight loss of about 22 lb (10 kg). His muscle loss is apparent to him, and he has severe cachexia.

Ulcerative colitis was diagnosed 10 years earlier. The patient received monthly doses of intravenous (IV) infliximab for 1 year. The biological therapy was stopped, and his disease is currently controlled on maintenance therapy with oral mesalamine.

He is a farmer and lives in a rural area. He was a heavy smoker (2 packs per day) but decreased his daily number of cigarettes to about 5 per day after ulcerative colitis was diagnosed. He has a long history of IV drug abuse; however, he denies any IV drug use within the past 3 years. He has no history of alcohol consumption.

The patient has no other relevant surgical or medical history. His brother has a history of Crohn's disease, and his grandfather died of a blood malignancy, although the patient does not know which type.


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