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

Sarah El-Nakeep, MD

Disclosures

September 12, 2022

A third possibility is lymphoma, which could occur in association with ulcerative colitis. The risk for gastrointestinal lymphoma increases in patients with ulcerative colitis who are older than 50 years, are male, have been receiving treatment for more than 4 years, or had previous Epstein-Barr virus infection.[7] This patient's beta-2 microglobulin level was 2 mg/L (reference range, 1.1 to 2.4 mg/L). Although this level is normal, it does not exclude lymphoma or blood cancer. Beta-2 microglobulin is considered a prognostic marker for malignant lymphoma.[8]

Both tuberculosis and lymphoma could explain the generalized enlargement of the lymph nodes and spleen in this patient. The splenic lesions appear to consist of not only solid focal lesions but also some cyst-like lesions. However, this finding does not exclude lymphoma, as a case has been reported of large B-cell lymphoma associated with cystic lesions in the spleen.[9]

The presence of splenic focal lesions and some cystic lesions could raise suspicion for hydatid disease. Further laboratory investigation is required with indirect hemagglutination (sensitivity of 85%), which remains positive for several years, or immunoelectrophoresis (sensitivity of 95%), which remains positive for only 1 year after eradication. In this patient, the hemagglutination test was negative.

The fact that some of this patient's lesions were solid is not typical of hydatid disease. This disease is caused by Echinococcus granulosus and most commonly involves the liver, followed by various internal organs, such as the lungs, kidneys, and brain, and bones. However, splenic cysts (splenic hydatidosis) tend to be asymptomatic unless they are complicated by infection or have ruptured. Usually, the cystic walls in the splenic cysts are calcified, and smaller neighboring "daughter" cysts are present.[10,11]

Ulcerative colitis could be complicated by toxic megacolon or colon cancer. The radiograph excluded toxic megacolon in the patient in this case. Ulcerative colitis affects the entire colon in 85% of patients who present with toxic megacolon, but the megacolon most commonly involves the transverse segment.[12]

To make a diagnosis in this case, colonoscopy and a CT scan of the abdomen and pelvis with contrast are necessary. However, colonoscopy in the patient's presenting state with intestinal obstruction was not feasible. The CT scan was performed early. Colonoscopy and biopsy were performed later, after 10 days, when his condition had stabilized, and the lesions in Figures 5-6 were revealed.

Figure 5.

Figure 6.

Although the patient's carcinoembryonic antigen level is within normal limits, it does not exclude the suspicion of cancer colon. The sensitivity of the carcinoembryonic antigen test for colon cancer is 80%, and the specificity is about 70%.[13] However, as shown in Figures 5-6, the colonoscopy and biopsy revealed nodular lesions with lymphomatous infiltration, and no signs of dysplasia or cancerous transformation. These findings excluded colon cancer.

The intestinal obstruction could be caused by ulcerative colitis activity or lymphomatous tissue infiltration. Both infection and lymphoma could explain the fever. Empiric antibiotic therapy was started despite the uncertainty of whether the fever was due to cancer or infection. Leaving the infection untreated might lead to septicemia, resulting in disseminated intravascular coagulation and thromboembolic disease.[14]

The patient received empiric therapy with a broad-spectrum antibiotic, meropenem (1 g every 8 hours in IV doses), which covers gram-positive and gram-negative organisms and anaerobes. After 72 hours, the fever resolved, and the abdominal pain decreased but did not disappear. Meropenem is used to treat acute peritonitis associated with intestinal perforation.[15] After 10 days, the blood culture revealed the presence of E coli infection.

The patient's CT scan showed splenic focal lesions, with some lesions exhibiting cystic transformation, along with a psoas abscess on the left side. Mild fluid collection in the abdomen was noted. The psoas abscess was drained with a pigtail catheter, and about 200 cc of pus was suctioned from the abscess. Cultures, which were sent for further bacteriologic and oncologic assessment, revealed E coli infection with increased WBCs, mainly neutrophilia, an elevated LDH level of 4000 U/L (reference range, 140-280 U/L for adults), and no tumor cells.

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