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نزف هضمي سفلي & نفخة انقباضية


نزف هضمي سفلي & نفخة انقباضية


حالة سريرية

الوصف الكامل Background
An elderly caucassian male brings in his wife, a 65 year old lady to their family physician with complaints of painless intermittent rectal bleeding. She describes the bleeding as bright red in color. She denies any abdominal pain, nausea or vomitting. Her medical history is significant for hypertension, diabetes mellitus, hypercholesterolemia.
Her vitals are:
BP: 140\80
PR: 80\m
RR: 16\m
T: 36.7
On examination an ejection systolic murmur is detected in the right second intercostal space. The remainder of the examination shows no abnormalities. Sigmoidoscopy is unremarkable. Which of these is the most likely diagnosis in this patient?
A- vascular actasia
B- diverticulosis
C- ischemic colitis
D- carcinoma colon
E- hemorrohids
SINA's picture
by
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بما أن تنظير السين طبيعي فالجواب أ

the best's picture
the best
طالب دراسات عليا


بما أن تنظير السين طبيعي فالجواب أ

the best's picture
the best
طالب دراسات عليا


هلأ الـ E- hemorrohids بتبين دائماً على التنظير؟

KMG's picture
KMG
طبيب مقيم


أشيع أسباب النزوف الهضمية السفلية وخاصة عند المسنين هي داء الرتوج, التوسع الوعائي, البواسير

the best's picture
the best
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vascular actasia

أشيع سبب للنزف الهضمي السفلي عند المسنين هو داء الرتوج وبعدهvascular actasia
لكن بما انو فيه نفخة اقباضية بالورب التاني منتوجه اتضيق الابهر يلي بيترافق عادة مع vascular actasia

a.m.a's picture
a.m.a
طبيب مقيم


صحيح
خاصة في CLUE بالقصة للتوسع الوعائي، شو هو؟؟

SINA's picture
SINA
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هلأ أول شي لازم ينعمل clolonoscopy with ileuscopy to rule out all of what's mentioned.
but in the question they didn't mention it
that means you don't need to do it in this case
vascular ectasia is the answer in this case.

مع اني مصر على اجراء colonoscopy.

dr.tabban's picture
dr.tabban


برافو ama هاد هو ال clue
تمام دكتور مهند نحنا عم نسأل عن التشخيص الأكثر احتمال مو عند التدبير.

the most common cause of lower GI bleed in elderly is diverticulosis. The second most common cause is vascular actasia or angiodysplasia. It usually presents in elderly patients with painless bleeding. There is a well defind association with aortic stenosis. The other well recognised association is renal failure. Most commonly bleeding originates from ascending colon or cecum.
It is difficult to differenciate between diverticular bleeding and angiodysplasia which both are common in people over 65 years old. However colonoscopy is diagnostic in both.
B: most diverticula are located in the sigmoid, so sigmoidoscopy would have shown these, and aortic stenosis makes angiodysplasia more probable.
C: ischemic colitis is unlikely in the absence of abdominal pain.
D: colon cancer is a possibility but the sigmoidoscopy did not show any mass and and aortic stenosis makes angiodysplasia more probable.
SINA's picture
SINA
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Sigmoidoscopy is unremarkable.??!!

It is the standered of care that such patient SHOULD undergo full colonscopy. Making a test question is actually an art. And the one who puts a question is not only testing people's knowledge but also teaching them something. When I put a question and mention the steps that were done to the patient then I am indirectly telling the reader what is considered to be the right approach for the patient symptoms or presentation
In this case I did not see that concept applied. I am leaning to believe that is was made decades ago and have not been
revised again
The other issue about the association with Aortic stenosis: this is mentioned in text books and some observations, Yet it is not well understood and it is not a cause-effect relatioship. Also Angiodysplastic lesions are very common even in normal hearts

ABIM's picture
ABIM

Quote:
sigmoidoscopy is unremarkable.??!
It is the standered of care that such patient SHOULD undergo full colonscopy. Making a test question is

I felt like they said that sigmoidoscopy was normal 2 make us exclude diverticulitis since most of the diverticula are located in the sigmooid.
by the way even if they said colonoscopy it wouldn't have done any difference, right?

Quote:
The other issue about the association with Aortic stenosis: this is mentioned in text books and some observations, Yet it is not well understood and it is not a cause-effect relatioship. Also Angiodysplastic lesions are very common even in normal hearts

thanx this information, but unfortunately we are still practicing medicine through text books

SINA's picture
SINA
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Quote:
even if they said colonoscopy it wouldn't have done any difference, right?

Right

ABIM's picture
ABIM
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