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

Sarah El-Nakeep, MD

Disclosures

September 12, 2022

Physical Examination and Workup

The patient's temperature is 102.2 °F (39 °C); his blood pressure is 90/70 mm Hg; his pulse is regular, at 110 beats/min; and his respiration rate is 20 breaths/min. Upon examination, he has generalized lymph node enlargement. Tender splenomegaly is noted. The abdominal examination reveals tenderness all over, with guarding and rigidity. The rectal examination shows no stool.

Laboratory investigations reveal these values:

  • Hemoglobin level: 8 g/dL (reference range, 13.2-17.1 g/dL)

  • Mean corpuscular volume: 80 fL (reference range, 80-100 fL)

  • White blood cell (WBC) count: 18,000 cells/µL (reference range, 4500-11,000 cells/µL)

  • Absolute neutrophil count: 1400 cells/µL (reference range, 2500-6000 cells/µL)

  • Platelet count: 150,000 cells/µL (reference range, 150,000-420,000 cells/µL)

  • Iron level: 45 µg/dL (reference range, 59-158 µg/dL)

  • Iron saturation: 15% (reference range, 15%-50%)

  • Ferritin level: 800 ng/mL (reference range, 30-400 ng/mL)

  • Erythrocyte sedimentation rate: 110 mm/h (reference range, 1-13 mm/h for males and 1-20 mm/h for females)

  • Lactate dehydrogenase (LDH) level: 2000 U/L (reference range, 140-280 U/L for adults)

  • Carcinoembryonic antigen level: 2.5 ng/mL (reference range, 0-2.9 ng/mL)

The fecal calprotectin level could not be measured, as the patient was constipated.

His ECG shows sinus tachycardia at a rate of 110 beats/min, with no other abnormality.

An erect radiograph of the abdomen reveals a lesion (Figure 1). A CT scan of the pelvis and abdomen with contrast is shown in Figures 2-4.

Figure 1.

Figure 2.

Figure 3.

Figure 4.

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