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

Sarah El-Nakeep, MD

Disclosures

September 12, 2022

Discussion

The patient in this case had known ulcerative colitis, for which he received biological therapy and then maintenance medical treatment. He now presents with fever that has not responded to a previous course of antibiotics, along with rectal bleeding and acute intestinal obstruction.

The intestinal obstruction is suggested by the presence of absolute constipation, absent flatus, and fluid levels on the erect radiograph shown in Figure 1. No bowel perforation is apparent, but this does not exclude a minute perforation if it presented without air under the diaphragm. The surgical consultants recommend medical observation, with nothing per mouth and fluid restriction.[1] Within 48 hours, the patient passes flatus and stools, and moderate abdominal gaseous distension is noted.

This patient is a farmer, which raises the possibility of intestinal tuberculosis. Mycobacterium bovis infection is a common zoonotic disease; however, this bacterium causes infection in humans through ingestion of contaminated milk on dairy farms. Over 71% of cases of extraintestinal tuberculosis result from gut infection by M bovis.[2] In this case, the patient's gastrointestinal tract could be the primary site of infection, with no lung involvement.[3]

Furthermore, the tuberculosis could be a new-onset infection or an activation of a latent infection. This patient had previous biological therapy, which might increase the possibility of tuberculosis owing to the suppressive effect on cellular T-lymphocyte function.[4] However, the patient's tuberculin test and his serum interferon-gamma release assay (QuantiFERON) were negative. In addition, the lesions on the CT scan showed no adhesions of the intestinal loops or encysted ascites.

A second possibility is infective endocarditis, owing to the patient's history of IV drug abuse. Infective endocarditis is unlikely to cause such large lymph node enlargement and cyst-like focal lesions in the spleen; instead, it usually leads to splenic infarctions due to splenic embolisms. A blood culture and a transesophageal echocardiogram (TEE) were ordered for this patient. The TEE did not show any vegetations or signs of active infection, but mild pericardial effusion was noted. The most common bacterial organism in IV drug users is Staphylococcus aureus, followed by group A streptococci. Gram-negative organisms are less common.[5] In this patient, the blood culture revealed Escherichia coli. Candidal infective endocarditis is reported to cause intestinal obstruction and is resistant to antibiotics.[6]

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