His and Hers Hematochezia - OHSU Sakai

His and Hers Hematochezia
Katie Camilleri, MD, Stephanie Halvorson, MD, Sima Desai, MD
Department of Medicine, Oregon Health & Science University, Portland OR.
Case Descriptions:
HPI: A 32 year old previously healthy woman presented to the ED with acute, progressive abdominal pain and bloody diarrhea. Four days prior to admission she and her boyfriend were
celebrating their recent move by drinking beer, eating fried chicken, potato salad, and jojos (potato wedges) at a fast food restaurant. The patient also reported snorting
methamphetamine. The next day she developed severe, epigastric, crampy abdominal pain, bloody diarrhea, nausea, and anorexia without any relief from antacids. ROS negative for
fevers, chills, or emesis, any sick contacts, recent travel, or family history of autoimmune disease or colitis.
Physical Exam:
Vitals: BP 112/68 | Pulse 88 | Temp 36.6 °C (97.8 °F) | RR 18 | SpO2 100%
General: middle aged woman intermittently curling up in fetal position in obvious distress
HEENT: no oral ulcers, lesions, or erythema, dry mucous membranes, no lymphadenopathy,
anicteric sclera
Abdomen: hypoactive bowel sounds, soft, non-distended, moderate tenderness to palpation of
the right upper quadrant with rebound and involuntary guarding, no organomegaly
Rectal: bloody loose stool mixed with mucous in the vault, no tenderness with digital rectal exam,
normal rectal tone, no internal or external hemorrhoids, well healed anal fissure.
Pertinent Laboratory Studies:
• WBC: 21 x103/µL, 85% neutrophils
• Hb: 14.8 g/dL
• Stool Culture: Negative for Salmonella, Shigella, Campylobacter, E. coli O157
• Shiga toxins 1 and 2: negative
• C . difficile toxin: negative
• Fecal Leukocytes: none
• HIV : negative
HPI: 39 year old previously healthy boyfriend of our previous patient presented to the emergency department for similar symptoms of three days of intolerable, severe, right upper
quadrant sharp and crampy abdominal pain, bloody diarrhea, and coffee ground emesis without fevers or chills. On discussion of the recent celebration, the patient endorsed eating the
fast food fried chicken and potato salad, drinking a moderate amount of alcohol, but having no methamphetamine use. He denies any sick contacts other than his girlfriend and no
recent travel, family history of colitis or autoimmune disease.
CT Abdomen/Pelvis:
Nonspecific right
sided colitis.
The wall of the right
colon, extending
from the cecum to
the mid transverse
colon, is
circumferentially
thickened to an
average diameter of
approximately 1.5cm.
Hospital Course: With supportive care of IV fluids, pain medications, anti-emetics, and bowel rest, her blood bowel movements, abdominal pain, and nausea resolved within four
days. Considering her negative infectious work up, the working diagnosis was possible ischemic colitis secondary to vasospasm from her recent methamphetamine use. An
outpatient colonoscopy scheduled to evaluate for possible inflammatory conditions .
CT Abdomen/Pelvis:
Continuous,
concentric, colonic
mural thickening with
adjacent free fluid
and fat stranding
from the cecum to
the splenic flexure.
Pertinent Laboratory Studies:
• WBC: 17 x103/µL, 81% neutrophils
• Hb: 15.7 g/dL
• Stool culture: Positive for E.coli serogroup O157:H7
• C difficile toxin: negative
Hospital Course: He received supportive care similar to his girlfriend and was discharged in four days without any complications or evidence of hemolytic uremic syndrome.
The Oregon State Health Department was notified.
Learning Points:
Discussion:
These cases highlight the poor sensitivity of stool cultures and only through serendipity was the diagnosis of shiga toxin producing E. Coli O157:H7 (STEC) made. Prior to the boyfriend’s diagnosis, the differential for the first patient included the
rare but reported finding of methamphetamine induced colitis . Ultimately, our patients did not suffer from the more feared complications of hemolytic uremic syndrome.
Methamphetamine Induced Vasoconstriction as a Cause of Mesenteric Ischemia
Meth-induced mesenteric ischemia is a rare phenomenon, having been reported only four times in the
literature. Those cases describe patients with severe abdominal pain with or without bloody diarrhea and
findings of right sided colitis with radiographic evidence of diffuse thickening of the walls of the colon, one of
which required hemi-colectomy.
The sympathomimetic stimulatory effects of methamphetamine commonly induces vomiting and diarrhea.
When associated with severe abdominal pain and bloody diarrhea, bowel ischemia should be considered,
especially with typical radiographic findings described above.
The vasoconstrictive properties of methamphetamine have been reported to also cause intracereberal
hemorrhage and occlusion, amaurosis fugax, peripheral vasospasm, and necrotizing angiitis.
Physical Exam:
Vitals: BP 166/98 | Pulse 104 | Temp 36.4 °C (97.5 °F) | RR 16 | SpO2 99%
General: middle aged man lying on his back holding his abdomen in his arms in moderate
distress
HEENT: no oral ulcers, lesions, or erythema, dry mucous membranes, no
lymphadenopathy, anicteric sclera
Abdomen: soft, non-distended, normoactive bowel sounds, tender to palpation in RLQ
and LLQ (RLQ>LLQ), no organomegaly, no rebound tenderness, guarding present.
Rectal: bright red blood in the vault, no hemorrhoids or fissures at the anus
Testing for Shiga Toxin Producing E. Coli (STEC):
Stool cultures can be unreliable in STEC, as the bacteria are only present in the stool for a few days and may not be detected by
culture even if they are present. In populations of STEC, the greatest yield of stool culture detection has been found to be
within the first 2 days of onset of diarrhea, with a drastic drop in detection rates beyond 7 days from onset of diarrhea.
-Although rare, methamphetamine can induce vasoconstriction and thus ischemic colitis
-Stool culture sensitivity is highest in the first two days of onset of symptoms
References:
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Shiga toxins themselves can be tested for with ELISA. This test has a high sensitivity, but is not specific to E. coli 0157 leading to
some false positives. Additionally, it does not provide identification of the serotype of the E. coli strain, which is important for
tracking outbreaks. The CDC recommends always performing both a culture and ELISA. Most laboratories automatically do this
if stool culture is being tested for E. coli O157.
Serologic testing for IgM and anti-lipopolysaccharide antibodies against most frequent STEC serotypes do exist and have 95%
sensitivity and 99% specificity in patients with positive stool cultures. However, the sensitivity and specificity of the serologic
tests are unclear in populations with negative stool cultures, making their value questionable in a clinical situations such as
these.
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Ludwig K, Bitzan M, Bobrowski C, Müller-Wiefel DE (2002). Escherichia coli O157 fails to induce a long-lasting lipopolysaccharide-specific,
measurable humoral immune response in children with hemolytic-uremic syndrome. J Infect Dis. 2002;186(4):566.
Tarr PI, Neill MA, Clausen CR, Watkins SL, Christie DL, Hickman RO (1990). Escherichia coli O157:H7 and the hemolytic uremic syndrome:
importance of early cultures in establishing the etiology. J Infect Dis. 1990;162(2):553.
Holubar SD, Hassinger JP, Dozois EJ, Masuoka HC. (2009). Methamphetamine colitis: a rare case of ischemic colitis in a young patient.
Arch Surg.2009 Aug;144(8):780-2.
Johnson TD, Berenson MM. (1991). Methamphetamine-induced ischemic colitis. J Clin Gastroenterol. 1991;13(6):687.
Cynthia A. Dirkx, MD, Eugenio O. Gerscovich, MD. (1998). Sonographic findings in meth-induced ischemic colitis. Journal of Clinical
Ultrasound 1998; 26:479-82.
Herr RD, Caravati EM. (1991). Acute transient ischemic colitis after oral methamphetamine ingestion. Am J Emerg Med. 1991 Jul;9(4):406-9.
Mackenzie AM, Lebel P, Orrbine E, Rowe PC, Hyde L, Chan F, Johnson W, McLaine PN. (1998). Sensitivities and specificities of premier E. coli
O157 and premier EHEC enzyme immunoassays for diagnosis of infection with verotxin (Shiga-like toxin)-producing Escherichia coli. J Clin
Microbiol. 1998;36(6):1608.
Kehl KS, Havens P, Behnke CE, Acheson DW. (1997). Evaluation of the premier EHEC assay for detection of Shiga toxin-producing Escherichia
coli. J Clin Microbiol. 1997;35(8):2051.