Question

This 50-year-old male patient, carpenter, stated that he has lost approximately 40 lbs since his last examination.

History: Patient says he has had no dysphagia or postprandial distress, and there is no report of diarrhea, nausea, emesis, hematemesis, or constipation. Patient has had a history or regional enteritis, appendicitis, and colon bleeding. The regional enteritis resulted in a ileosotmy with appendectomy about 6 months ago.

Assessment: His sigmoidoscopy using a 10-cm scope showed no evidence of bleeding at the anorectal area. A 35-cm scope was then inserted to a level of 13 cm. At this point, angulation prevented further passage of the scope. No abnormalities had been encountered, but dark blood was noted at that level.

Impression: My impression is that the rectal bleeding could be caused by a polyp, ulcerative colitis, or colorectal carcioma.

Plan: Patient has been advised to schedule a colonoscopy next week and to come to the emergency department if symptoms worsen.


If you were the gastroenterologist, what would your diagnosis be based on the information provided in the case study?

Answer 1

The most likely diagnosis would be ulcerative colitis, given the patient's history of regional enteritis and the finding of dark blood at the level of the sigmoidoscope.

Do not use this as a medical diagnosis, consult a professional.