You are describing a Schönlein-Henoch purpura which is a vasculitic phenomenon, so the lesions are not due to plateletopenia. Scrotal edema (sometimes even torsion of Morgani's capsid of the testis) is not exceptional in males with S. Schönlein-Henoch.

A 4-year-old boy consulted for the appearance over the last three days of skin lesions on the legs and buttocks. His parents reported that his pediatrician had diagnosed an upper respiratory tract infection 10 days earlier. In the last 12 hours she presented intense colicky abdominal pain and had two diarrheal stools. Afebrile. No weight loss. On examination she has numerous petechiae and palpable purpuric lesions predominantly on the buttocks and lower extremities. Good general condition although she has intense abdominal pain. Abdominal palpation is difficult to assess due to diffuse pain. No visceromegaly. No other findings of interest on examination. Which of the following data does NOT support your diagnostic suspicion?

A patient with abdominal distension.

A 74-year-old woman was admitted to our hospital because of vomiting and abdominal pain. She had been well until 24 hours before admission, when she had had her last meal. She had not eaten anything unusual. She developed pain in the left lower abdominal quadrant, and difficulties with her bowel movements. An enema was given unsuccessfully. There was progressive distension of the abdomen. The patient started to vomit gastric and later bilious contents. No history of abdominal symptoms or weight loss was reported. She currently takes oral antidiabetic agents and an angiotensin II blocker because of hypertension. On physical examination she was not in distress and was afebrile, blood pressure 130/100 mmHg, pulse rate 88 beats/min. On auscultation increased bowel sounds with rushes of high-pitched sounds were heard. Her abdomen was distended and a large tender mass filling the whole left lower quadrant without signs of peritoneal irritation was found. There were no faeces on rectal examination. The leucocyte count was 10.2 mmol/L, haemoglobin 7.2 mmol/L, C-reactive protein 36 mg/l and lactate dehydrogenase 535 U/l. Under suspicion of a mechanical bowel obstruction without signs of peritonitis, the patient was treated with a nasogastric tube, fasting and enemas on which she improved. An abdominal X-ray in bed taken on day two showed no bowel distension (figure 1). After removing the nasogastric tube on day two the nausea returned. Abdominal examination was unchanged. An abdominal computed tomography (CT) scan after drinking oral contrast and intravenous contrast was performed (figure 2).

An extremely uncommon case of parasitic infection presenting as eosinophilic ascites in a young patient.

We report the case of a 24-year-old male patient admitted for recent ascites and splenomegaly of unknown origin. The patient was referred to our institution with complaints of diarrhea, epigastric pain, abdominal cramping and weight loss over the past three weeks. The acute onset presented with colicky abdominal pain and peritoneal effusion. History revealed reduced appetite and weight gain of 7 kg over the last one month. His past medical history and family history was negative. He had no history of alcohol abuse or viral hepatitis infection. Laboratory data revealed normal transaminases and bilirubin levels, and alkaline phosphatase and gammaglutamyltransferase were within normal range. A diagnostic laparoscopy was performed which showed free peritoneal fluid and normal abdominal viscera. Upper gastrointestinal system endoscopy performed a few days later revealed diffuse severe erythematous pangastritis and gastroduodenal gastric reflux. Duodenal biopsies showed chronic nonspecific duodenitis. Antrum and corpus biopsies showed chronic gastritis. The ascitic fluid was straw-colored and sterile with 80% eosinophils. Stool exam was negative for parasitic infection. Treatment with albendazole 400 mg twice daily for 5 days led to the disappearance of ascites and other signs and symptoms. Three months after albendazole treatment the eosinophilic cell count was normal. The final diagnosis was consistent with parasitic infection while the clinical, sonographic and histological findings suggested an eosinophilic ascites. We emphasize the importance of excluding parasitic infection in all patients with eosinophilic ascites. We chose an alternative way (albendazole treatment) to resolve this clinical picture. With our alternative way for excluding this parasitic infection, we treated the patient and then found the cause.

Henoch–Schönlein purpura

Purpura, arthritis, and abdominal pain are known as the "classic triad" of Henoch–Schönlein purpura. Purpura occur in all cases, joint pains and arthritis in 80%, and abdominal pain in 62%. Some include gastrointestinal hemorrhage as a fourth criterion; this occurs in 33% of cases, sometimes, but not necessarily always, due to intussusception. The purpura typically appear on the legs and buttocks, but may also be seen on the arms, face and trunk. The abdominal pain is colicky in character, and may be accompanied by nausea, vomiting, constipation or diarrhea. There may be blood or mucus in the stools. The joints involved tend to be the ankles, knees, and elbows, but arthritis in the hands and feet is possible; the arthritis is nonerosive and hence causes no permanent deformity. Forty percent have evidence of kidney involvement, mainly in the form of hematuria (blood in the urine), but only a quarter will have this in sufficient quantities to be noticeable without laboratory tests.

Amoebic liver abscess

A amoebic liver abscess is a type of liver abscess caused by amebiasis. It is the involvement of liver tissue by trophozoites of the organism Entamoeba histolytica and of its abscess due to necrosis. Presentation Approximately 90% of patients with E histolytica are asymptomatic. The two most common manifestations of E histolytica include colitis (bloody stool with mucus, abdominal pain, and/or diarrhea), and discovery of a liver abscess on imaging. Liver abscess' commonly present as right upper quadrant abdominal pain and fever, with worsening features associated with abscess rupture. Symptoms Pain right hypochondrium referred to the right shoulder Pyrexia (100.4 F) Profuse sweating and rigors Loss of weight Earthy complexion Signs Pallor Tenderness and rigidity in right hypochondrium Palpable liver Intercostal tenderness Basal lung signs

Natural killer cell enteropathy

Most cases of NKCE and LG have been reported in middle-aged or older individuals. Patients diagnosed with NKCE (medium age 46 years) have presented with vague abdominal pain, indigestion, vomiting, diarrhea, constipation, weight loss, anemia, and/or GI bleeding. Two patients complained of biliary colic (i.e. gallbladder pain) and were found to have typical lesions of NKCE in their cystic ducts. These two cases indicate that NKCE involvement is not totally limited to the alimentary canal. Three of 15 individuals diagnosed with NKCE disease reported no symptoms, their disease being found on endoscopy conducted for screening purposes. Typically, patients diagnosed with LG (medium age 58 years) have been asymptomatic at presentation with their disease being detected during GI tract examinations done for other reasons. Three of twenty patients diagnosed with LG complained of pain or discomfort in the upper abdominal region. Symptomatic individuals with either disease generally have a long

Palpable purpura and a visible sock line.

A 21-year-old woman came to the clinic, frightened by a painful purpuric rash on her lower extremities. The lesions appeared suddenly 3 days before, with no prior similar episodes. The pain, and some swelling that happened when she stood, had finally driven her to take some time off from her job and seek medical advice. She was diagnosed with a case of pharyngitis earlier that week; due to multiple drug allergies, she was prescribed a course of clindamycin. She had not experienced any nausea or vomiting, fever, abdominal cramping, or gross hematuria. On examination, the patient was friendly and good-humored, although she was concerned about her rash and visibly uncomfortable. She was walking with the aid of a borrowed cane, but her lesions were no longer tender to palpation. The rash consisted mainly of purpuric papules almost entirely limited to her legs, although some isolated lesions were on her back as well. The papules were concentrated around her distal lower extremities, with a clear line of lesions encircling her calves bilaterally where her knee-high socks had applied pressure for the last 2 days. Mild edema was noted, but the rest of her physical exam was normal. By dipstick, the patient had blood in her urine but no protein. What is the diagnosis? What is the treatment for this condition?

[Comparison of symptoms and clinical and laboratory findings in the first and last weeks of typhoid fever].

In this study we examined the clinical and laboratory findings of 80 in-patients. There is an important difference between sexes (p greater than 0.05). Comparison of ages showed that 7-30 age is more vulnerable than the older group. We found clinical symptoms of fever, chills, headache, abdominal pain, disturbances in bowel function, nausea, vomiting, anorexia, and lassitude in the first two weeks more frequently when compared with the 3rd, 4th, 5th weeks of illness (p less than 0.001). Where physical finding of rose spots, discordant pulse rate are important in the first two weeks (p less than 0.001). Abdominal discomfort is an important symptom both in the first two and in the last three weeks (% 40.3 and % 36 respectively). Hepatomegaly and splenomegaly, were found more frequently in the last three weeks. According to laboratory findings of anemia, leukopenia, increased erythrocyte sedimentation rate and positive blood and feces cultures there is no important difference between the first two and last three weeks (p greater than 0.05). Increase in polynuclear leucocytes is important for the first two weeks, and increase in lymphocytes is important in the last three weeks (p less than 0.001). Positivity of group agglutination tests is 57%, in the first two weeks and 83% in the last three weeks. This difference is found to be important.

An 8-month-old boy with purpuric skin lesions. Acute hemorrhagic edema of infancy.

A previously healthy 8-month-old Hispanic boy presented with a 5-day history of an erythematous, non-pruritic papular eruption on both legs. The eruption was initially diagnosed as impetigo by his primary care practitioner but progressed despite trimethoprim / sulfamethoxazole therapy, with extension to the face, trunk, and all extremities. When the patient subsequently developed a fever of 100.8° F, emesis, diarrhea, and upper respiratory symptoms, he was referred to the pediatric dermatology clinic for evaluation. Further questioning revealed a 3-day febrile illness 6 weeks prior to presentation that was treated with ceftriaxone. Review of systems failed to identify any hematuria, blood in stool, or abdominal pain, but the parents did report swelling of the extremities and face, as well as decreased oral intake. On examination, the infant was in no apparent distress, afebrile, and had mild rhinorrhea. His mucous membranes were unaffected, and no lymphadenopathy or hepatosplenomegaly was noted. Cutaneous exam revealed numerous edematous erythematous to violaceous plaques on the cheeks, arms, buttocks, and legs with minimal involvement of the trunk. Several lesions on the arms had a distinct cockade (rosette or iris-like) pattern. There were no vesicles, bullae, or necrosis. Edema of the bilateral lower extremities was noted. Laboratory work up revealed a normal complete blood count (CBC), comprehensive metabolic panel, creatinine, and urinalysis. Platelets were borderline elevated at 439 TH/μL (140-440 TH/μL), and erythrocyte sedimentation rate and C-reactive protein (CRP) were minimally elevated at 22 mm (0-15 mm) and 3.1 mg/dL (0.0-0.99 mg/dL), respectively.

[Severity assessment of acute diarrhoea].

Clinician should recognize any life-threatening causes of diarrhoea, such as intussusceptions, surgical abdomen, and haemolytic uraemic syndrome. The following clinical features should alert: abdominal pain with tenderness, with or without guarding, pallor, jaundice, oligo-anuria, bloody diarrhoea, systemically unwell out of proportion to the level of dehydration, shock. The risk of dehydration is related to age (highest in young infants<6 months), and frequency of watery stools (>8/day) and vomiting (>2/day before 1 year and >4/day after 1 year), but these historical points have a moderate sensitivity. The severity of dehydration is rarely estimated with accuracy in terms of weight loss (third sector with full colon, absence of accurate baseline pre-dehydration weight). Combinations of examination signs perform markedly better than any individual sign in predicting dehydration (poor rate agreement, clinically unhelpful likelihood ratio). The presence of at least three signs better correlate with dehydration. Laboratory tests are not helpful. New studies are mandatory to validate severity scoring systems.

Brodifacoum

In another case reported in 2013, a 48-year-old female patient reported 4 days of mild dyspnea, dry cough, bilateral popliteal fossae pain, and diffuse upper abdominal pain. She had no history of liver disease or alcohol or illicit substance abuse. Initial physical examination was remarkable only for mildly pale conjunctivae and mild abdominal tenderness and pain in the left popliteal fossa. A complete blood count and complete metabolic panel were normal. Prothrombin time (PT) was above 100 s, partial thromboplastin time (PTT) was above 200 s and international normalized ratio (INR) was reported as above 12.0. Urinalysis revealed hematuria (blood in the urine). Venous Doppler ultrasound of lower extremities demonstrated left popliteal vein thrombosis. Computed tomography scan of the abdomen demonstrated transmural hematoma, and a fecal occult blood test was positive. A full anticoagulant work-up showed critical reduction of vitamin K-dependent factors II, VII, IX, and X. PT and PTT

Amebic Colitis -- History and Physical

On physical examination, the patient may have either localized or diffuse tenderness on palpation. Rarely, a palpable mass may be present. If undiagnosed and untreated, a patient may present with toxic megacolon, which presents as an acute dilatation of the colon. This complication carries a high mortality due to associated necrosis and perforation. Fewer than 1% of patients with amebic colitis have associated extraintestinal infection, the commonest being a liver abscess. Patients with liver abscesses may have symptoms such as fever, chills, and pain in the upper right quadrant or can be asymptomatic. Weight loss, increased white blood cell counts, or elevated liver enzyme levels may be present. Jaundice is usually absent. [13] Lung abscesses may develop due to penetration of the diaphragm by amebae from hepatic abscesses or hematogenous spread. Invasion of the lung can cause symptoms such as chest pain, dyspnea, and a productive cough. [14]

[Chronic diarrhea: clinical aspects].

A retrospective study on the syndrome of chronic diarrhea was carried out on 50 revised clinical histories. The patients were hospitalized at the E. Rebaglati M. Hospital between April 1983 and March 1988. The purpose of the study was to evaluate the signs and symptoms of the syndrome, as well as the etiological agents and the methodology used for diagnoses. The selection criteria involved patients diagnosed as suffering from "chronic diarrhea of undetermined causes" upon entry. Seven were excluded due to incomplete study whereas 2 were diagnosed as acute infections diarrhea. Forty one patients were definite cases of chronic diarrhea and they were divided between 2 groups: the first one or Chronic Organic Diarrhea (58.53%) and the second one or Chronic Functional Diarrhea (41.46%). Out of the 41 revised clinical histories with chronic diarrhea, the following were the foundings: (1) the syndrome affects the economically active populations mainly and the length of the disease was more than 3 weeks in all the patients; (2) anemia, fever, weight loss, nightime bowel movements and bloody stools suggest organic problems whereas psychiatric disorders, daytime bowel movements, abdominal pain, disease recurrence and absence of detectable organic pathology suggest functional problems; (3) the most common cause of chronic diarrhea is the Irritable Bowel Syndrome followed by infectious diseases, with parasitosis in the first place; and (4) bearing in mind the mainly colonic affection and the predominant infectious diseases, the methodology used for their diagnosis would bring out good results.

A Case of Henoch-Schönlein Purpura with P369S Mutation in MEFV Gene.

Henoch-Schönlein purpura (HSP) is the most common vasculitis of childhood. HSP can affect multiple organs presenting with a characteristic rash in most of the patients. Familial Mediterranean Fever (FMF) is an inherited inflammatory disease common in mediterranean populations. HSP is the most common vasculitis seen in children with FMF. A 16 year old boy was referred with history of abdominal pain lasting for 20 days. He was hospitalized and had appendectomy. Due to the persistence of his abdominal pain after surgery he was admitted to our hospital. His physical examination showed palpable purpuric rashes symmetrically distributed on lower extremities. Abdominal examination revealed periumbilical tenderness. Laboratory tests showed elevated erythrocyte sedimentation rate, Creactive protein and fibrinogen. Urinalysis revealed microscopic hematuria and severe proteinuria. The fecal occult blood testing was positive. Based on these clinic findings, the patient was diagnosed as HSP with renal, gastrointestinal tract and skin involvement. We performed DNA analysis in our patient because he had diagnosis of vasculitis with severe symptoms and found that he was carrying heterozygote P369S mutation. Our case is noteworthy as it indicates that it may be important not to overlook presence of FMF mutations in patients with a diagnosis of severe vasculitis.

Red flags of organic recurrent abdominal pain in children: study on 100 subjects.

A variety of sign, symptoms and laboratory findings are more common in children with organic abdominal pains. This study was performed to evaluate the prevalence of organic and functional abdominal pains and relation of red flags to organic pains in 100 children with recurrent abdominal pain (RAP). One hundred consecutive patients with RAP were enrolled in the study. A complete interview and physical examination was made for each patient, accompanied by a series of laboratory, clinical and para-clinical examinations. The data were recorded and analyzed. Logistic regression analysis was used to model and formulize correlations between sign, symptoms, and laboratory findings with organic and functional abdominal pain. Among 100 patients (52% male, 48% female, Age: 9.29±3.17) diagnostic works up revealed organic pain for 57 patients. The most common symptoms of the patients included constipation, diarrhea, chest pain, cough, headache, vomiting, hematuria, and dysuria. Fecal incontinence, delayed puberty, organomegaly, jaundice, and family history of inflammatory bowel disease were reported in none of the patients with RAP. Fever, pain not located in periumbilical area, nocturnal pain, elevated erythrocyte sedimentation rate, weight loss, growth disorder, and abdominal tenderness were among the red flags which revealed diagnosis of organic pain in this study. A series of red flags could increase likelihood of finding organic pain in children with RAP.

Henoch-Schönlein purpura in an older man presenting as rectal bleeding and IgA mesangioproliferative glomerulonephritis: a case report.

Henoch-Schönlein purpura is the most common systemic vasculitis in children. Typical presentations are palpable purpura, abdominal pain, arthritis, and hematuria. This vasculitic syndrome can present as an uncommon cause of rectal bleeding in older patients. We report a case of an older man with Henoch-Schönlein purpura. He presented with rectal bleeding and acute kidney injury secondary to IgA mesangioproliferative glomerulonephritis. A 75-year-old Polish man with a history of diverticulosis presented with a five-day history of rectal bleeding. He had first noticed colicky left lower abdominal pain two months previously. At that time he was treated with a 10-day course of ciprofloxacin and metronidazole for possible diverticulitis. He subsequently presented with rectal bleeding to our emergency department. Physical examination revealed generalized palpable purpuric rash and tenderness on his left lower abdomen. Laboratory testing showed a mildly elevated serum creatinine of 1.3. Computed tomography of his abdomen revealed a diffusely edematous and thickened sigmoid colon. Flexible sigmoidoscopy showed severe petechiae throughout the colon. Colonic biopsy showed small vessel acute inflammation. Skin biopsy resulted in a diagnosis of leukocytoclastic vasculitis. Due to worsening kidney function, microscopic hematuria and new onset proteinuria, he underwent a kidney biopsy which demonstrated IgA mesangioproliferative glomerulonephritis. A diagnosis of Henoch-Schönlein purpura was made. Intravenous methylprednisolone was initially started and transitioned to prednisone tapering orally to complete six months of therapy. There was marked improvement of abdominal pain. Skin lesions gradually faded and gastrointestinal bleeding stopped. Acute kidney injury also improved. Henoch-Schönlein purpura, an uncommon vasculitic syndrome in older patients, can present with lower gastrointestinal bleeding, extensive skin lesions and renal involvement which responds well to systemic steroid therapy. A history of diverticulosis can mislead physicians to the diagnosis of diverticular bleeding which is more common in this age group. The clinical manifestations of the disease, including characteristic skin rash, abdominal pain, joint inflammation and renal involvement raised the suspicious of Henoch-Schönlein purpura.

InternalMed_Harrison

Amebic Liver Abscess Extraintestinal infection by E. histolytica most often involves the liver. Of travelers who develop an amebic liver abscess after leaving an endemic area, 95% do so within 5 months. Young patients with an amebic liver abscess are more likely than older patients to present in the acute phase with prominent symptoms of <10 days’ duration. Most patients are febrile and have right-upperquadrant pain, which may be dull or pleuritic in nature and may radiate to the shoulder. Point tenderness over the liver and right-sided pleural effusion are common. Jaundice is rare. Although the initial site of infection is the colon, fewer than one-third of patients with an amebic abscess have active diarrhea. Older patients from endemic areas are more likely to have a subacute course lasting 6 months, with weight loss and hepatomegaly. About one-third of patients with chronic pre sentations are febrile. Thus, the clinical diagnosis of an amebic liver abscess may be difficult to

An unusual cutaneous manifestation of Crohn's disease.

A 61-year-old man with a 12-year history of quiescent Crohn's disease on mesalamine presented to his gastroenterologist in April 2009, complaining of abdominal cramping, diarrhea, and a 25-lb weight loss over 6 weeks. He did not respond to prednisone 50 mg and 6-mercaptopurine 100 mg daily. Abdominal computed tomography findings revealed diffuse submucosal edema consistent with extensive colitis. Colonoscopy demonstrated diffuse inflammation with erythema, friability, and shallow ulcerations in the rectum and colon. Biopsies were consistent with Crohn's colitis. He was admitted for infliximab infusion for his unremitting diarrhea. Five days before admission, the patient noted mild swelling and redness of the left lower eyelid, which progressed to involve the right lower eyelid with frank pus draining from both eyes. He had no visual impairment or eye pain. Two days before admission, an ophthalmologist prescribed a steroid eyedrop with no relief. He also complained of seropurulent painful skin lesions on his face and scalp, which spread to involve his upper trunk and proximal arms. On admission to the hospital, dermatology, ophthalmology, and infectious disease consultations were obtained to rule out disseminated infection before initiation of infliximab therapy. The patient was afebrile and hemodynamically stable. His oral mucosa was normal. He had prominent bilateral lower eyelid edema, erythema, and superficial erosions with hemorrhagic crusting and frank green purulent drainage from both eyes, with crusting along the lower lash line and bilateral sclera injection (Figure 1). On his scalp, face, trunk, and proximal extremities, he had 25 to 30 erythematous, 4- to 8-mm papulopustules with narrow red halos, some with central necrosis and crusting (Figure 2). Cultures from the purulent ocular drainage and pustules on the trunk and arms were all negative for bacteria, virus, and fungi. Gram stain from the eye drainage showed polymorphonuclear leukocytes without organisms. Tissue cultures were negative for bacterial, fungal, and mycobacterial infection. Skin biopsy taken from the central upper back demonstrated subcorneal pustules with areas of eroded epidermis and collections of neutrophils in the superficial dermis (Figure 3). Special stains were negative for organisms. He received infliximab infusion 5 mg/kg for a total dose of 420 mg over 2 hours. Within 48 hours of infusion, there was notable decrease in size of lesions, in addition to reduction of purulent drainage from both eyes. The patient was discharged home following infliximab infusion. His skin lesions resolved during a period of 2 weeks, leaving small pink atrophic scars. He received his second infusion of infliximab 2 weeks after discharge with continued improvement in his gastrointestinal symptoms.

[Diagnosis of abdominal tuberculosis in children].

To improve the recognition and diagnosis of abdominal tuberculosis (TB) in children. The data from 30 cases with abdominal TB hospitalized in Beijing Children's Hospital were analyzed retrospectively. The clinical significance of various tests was discussed respectively. Twenty of the 30 cases were misdiagnosed as having upper respiratory tract infection, gastroenteritis, indigestion, and only 6 cases were diagnosed as pulmonary tuberculosis while the diagnosis of abdominal TB was made in just 4 cases at initial consultation. Twenty-one cases (70%) experienced the symptoms of abdominal pain or distension, diarrhoea, or constipation. The positive abdominal signs existed in all children including doughy sensation (9 cases), tenderness (8 cases), mass (4 cases), and hepatosplenomegaly (3 cases). Extraabdominal TB was found in 24 children, the positive PPD and abnormal ultrasonic image were seen in 93% and 100% of the cases, respectively. The exploratory laparotomy and colonoscopic biopsy confirmed the diagnosis in 3 and 2 cases, respectively. Twenty-four children received systematic treatment with good results. The abdominal TB in children which is easily misdiagnosed in it's early stage usually consisted of gastrointestinal symptoms and signs. The TB beyond the abdomen can be a clue for making correct diagnosis. PPD and ventral ultrasonic examination are important for ultimate clinical diagnosis while colonoscopy, and laparotomy can provide pathological evidence.

Intussusception (medical disorder)

Signs and symptoms Early symptoms can include periodic abdominal pain, nausea, vomiting (sometimes green in color from bile), pulling legs to the chest area, and intermittent moderate to severe cramping abdominal pain. Pain is intermittent—not because the intussusception temporarily resolves, but because the intussuscepted bowel segment transiently stops contracting. Later signs include rectal bleeding, often with "red currant jelly" stool (stool mixed with blood and mucus), and lethargy. Physical examination may reveal a "sausage-shaped" mass, felt upon palpating the abdomen. Children, or those unable to communicate symptoms verbally, may cry, draw their knees up to their chest, or experience dyspnea (difficult or painful breathing) with paroxysms of pain. In neonates it may present with bilious vomiting and blood stained stools

Dientamoebiasis

Dientamoebiasis is a medical condition caused by infection with Dientamoeba fragilis, a single-cell parasite that infects the lower gastrointestinal tract of humans. It is an important cause of traveler's diarrhea, chronic abdominal pain, chronic fatigue, and failure to thrive in children. Signs and symptoms The most commonly reported symptoms in conjunction with infection with D. fragilis include abdominal pain (69%) and diarrhea (61%). Diarrhea may be intermittent and may not be present in all cases. It is often chronic, lasting over two weeks. The degree of symptoms may vary from asymptomatic to severe, and can include weight loss, vomiting, fever, and involvement of other digestive organs. Symptoms may be more severe in children. Additional symptoms reported have included: Weight loss Fatigue Nausea and vomiting Fever Urticaria (skin rash) Pruritus (itchiness) Biliary infection Cause

Unusual Presentation of Methicillin-Resistant <i>Staphylococcus aureus</i> Colitis Complicated with Acute Appendicitis.

Clostridium difficile colitis has been the most recognized bacterial enterocolitis for years and other bacteria such as Staphylococcus colitis has been relegated. Staphylococcus enterocolitis following antibiotics had been one of the most frequent complications in surgical patients in the 1950s and 1960s and now reappear with more resistance such as methicillin-resistant<iStaphylococcus aureus</i(MRSA) colitis which brings a new challenge. A 32-year-old Hispanic female with a history of type I diabetes mellitus presenting with altered sensorium and a 2-day history of watery, nonbloody diarrhea, intractable emesis, and diffuse crampy abdominal pain. About a month before the presentation, the patient had a soft-tissue laceration on the left foot requiring a 7-day course of cephalexin and clindamycin that healed appropriately. On physical examination, she was tachycardic with heart rate of 110 bpm and tachypneic with respiratory rate of 28, somnolent but arousable with the Glasgow Coma Scale >12. The abdomen was soft, tender diffusely to palpation without rebound or guarding. On the biochemical analysis, her blood glucose was 968 mg/dL with anion gap metabolic acidosis (AG 46). In the intensive care unit, she initiated on intravenous (IV) fluids, insulin, and IV antibiotics for suspicion of colitis. Clostridium difficile testing was negative, but stool cultures grew MRSA for which she was started on vancomycin and TMP-SMX. Due to continued abdominal pain on antibiotics, computed tomography of the abdomen with contrast showed acute appendicitis with inflammatory debris and without perforation or abscess requiring laparoscopic appendectomy. Our case presented with diabetic ketoacidosis (DKA), which complicates the etiology of abdominal pain on admission for the clinician masking-MRSA colitis associated with a rare complication of appendicitis double challenge and difficult to diagnose as most DKA patients present with abdominal pain. This is the first case report describing MRSA enterocolitis in patient with DKA complicated by acute appendicitis.

Pseudoappendicitis -- History and Physical

Y enterocolitica infections are mostly asymptomatic. However, mild abdominal pain and diarrhea may occur. Severe yersiniosis presents with watery or bloody diarrhea, fever, chills, and increased abdominal pain. If mesenteric lymph nodes are involved, patients will have moderate-to-severe right lower quadrant abdominal pain, which could masquerade as acute appendicitis. These patients may exhibit abdominal guarding and rebound tenderness with a positive McBurney sign, predicting localized terminal ileitis. Patients with severe watery or bloody diarrhea may be misdiagnosed with salmonellosis, shigellosis, or Giardia enteritis. Patients with advanced infections, mainly if left untreated, may present with signs of sepsis, dehydration, and shock. [11]

Nephritic syndrome

Children/adolescents IgA nephropathy (Note: Contrast time of onset with Post-streptococcal Glomerulonephritis) - Most commonly diagnosed in children who recently had an upper respiratory tract infection (URI). Symptoms typically present within 1–2 days of a non-specific URI with severe flank/abdominal pain, gross hematuria (characterized by dark brown or red colored urine), and edema of the hands, feet, and/or face. Post-streptococcal glomerulonephritis (PSGN) - Similar to IgA nephropathy, post-streptococcal glomerulonephritis (PSGN) most often occurs in children who have recently had an upper respiratory infection (URI). In contrast with IgA nephropathy, however, PSGN typically presents 2–3 weeks after recovering from an URI that was caused specifically by a Streptococcus bacteria. The symptoms at onset are very similar to IgA nephropathy and include abdominal pain, hematuria, edema, and oliguria.

A Case of an 11-year-old With Cough, Diarrhea, and Findings of Concern in His Lungs and Spleen.

This is the case of a previously healthy, 11-year-old male of Indian descent who presented to the emergency department with a 2-month history of nausea, vomiting, diarrhea, fatigue, cough, and 7-lb weight loss. Acutely, he developed 5 days of fever as high as 39.4°C. He had a remote travel history to the Middle East. On physical examination, he was febrile and tachycardic, was thin but otherwise had a normal examination. His inflammatory markers were elevated: erythrocyte sedimentation rate was 93 mm/hour and his C-reactive protein was 25.4 mg/L. A complete blood count revealed a white blood cell count of 17,000 × 10(3)/µL with increased bands. His hemoglobin level was 8.8 g/dL with a mean corpuscular volume of 81 fl. Platelets were 556 × 10(3)/µL. A chest radiograph was concerning for a cavitary lung lesion and an abdominal ultrasound revealed multiple hypoechoic lesions in his spleen. Our panel of experts reviews his case and examines the workup of this patient with diverse symptoms and focal findings on chest radiograph and abdominal ultrasound.

Adult-Onset Immunoglobulin A Vasculitis With Renal Involvement.

A 50-year-old male presented with worsening bilateral lower extremities swelling for a month, associated with a purpuric rash over bilateral upper and lower extremities, joint pain over bilateral hands and ankles, and intermittent generalized abdominal pain. Physical examination was notable for pitting edema in bilateral lower extremities and palpable, non-blanching purpuric rashes and crusts, joint tenderness over bilateral hands/wrists/ankles, and mild generalized abdominal tenderness. Laboratory tests were remarkable for sub-nephrotic range proteinuria and microscopic hematuria. The skin biopsy revealed leukocytoclastic vasculitis. Renal biopsy showed mild mesangial expansion and immunoglobulin A (IgA)-dominant mesangial deposits. The patient was diagnosed with IgA vasculitis (IgAV) nephritis (IgAVN) and was subsequently treated with oral prednisone 80 mg daily for seven days followed by slow tapering doses, oral lisinopril 2.5 mg daily, and oral furosemide 40 mg daily. At the one-month follow-up as an outpatient, his skin rash and lower extremity swelling had resolved along with an improvement of proteinuria.

Gastrointestinal Tuberculosis -- History and Physical

Patients with gastrointestinal tuberculosis commonly present with the following complaints: [10] [37] Abdominal pain Anorexia Fever Change in bowel habits – diarrhea more common than constipation Nausea and vomiting Melena However, some patients may not manifest any symptoms of GI TB. [38] On examination, they are commonly found to have the following signs: [10] [37] Weight loss Pallor and anemia Rectal bleeding Abdominal distension and ascites Hepatomegaly Splenomegaly Lymphadenopathy Abdominal mass

[Adrenal hemorrhage in a patient with systemic lupus erythematosus].

A 58-year-old female was referred to our department with intermittent suffocation for 1.5 years, aggravated for a month. 1.5 years before she developed oral ulcer, raynaud phenomenon, proteinuria, bilateral pleural effusion, ANA and anti-dsDNA positive. This patient was diagnosed with systemic lupus erythematosus (SLE). After given hormones, hydroxychloroquine sulfate (HCQ), her symptom relieved soon. The patient stopped her pills 1 year ago. One month ago, she had chest tightness, increased urine foam, and suffered from oliguria. Her admission medical examination: blood pressure (BP) 130/80 mmHg, conjunctiva pale, and lower lung breath sounds reduced. There was no tenderness, rebound pain and abdominal muscle tension in the abdomen. Liver and spleen rib inferior, mobile dullness negative, and lower extremity edema. Blood routine tests were performed with hemoglobin (HGB) 57 g/L. Urine routine: BLD (3+). 24-hour urinary protein 3.2 g. serum albumin 20.5 g/L, C-reactive protein (CRP) 12.85 mg/L, erythrocyte sedimentation rate (ESR) 140 mm/h. Antinuclear antibody (ANA) (H)1:10 000, anti-dsDNA antibody 1:3 200; anti-Smith antibody, anti-U1-snRNP/Sm antibody were positive, blood complement 3(C3) 0.43 g/L, complement 4(C4) 0.07 g /L. Anticardiolipin antibody (ACL), anti-β2-GP1, lupus anticoagulant (LA) were negative; HRCT suggested bilateral medial pleural cavity product liquid. Admission diagnosis: SLE lupus nephritis, anemia, pleural effusion, and hypoproteinemia. We treated her with methylprednisolone 1 000 mg×3 d, late to 48 mg/d and cyclophosphamide 1.0 g, HCQ 0.2 g bid, gamma globulin 10 g×5 d. Day 2 of treatment, this patient developed acute right upper quadrant pain, not accompanied by nausea, vomiting, blood stool and diarrhea. Antipyretic antispasmodic treatment was invalid, after the morning to ease their own abdominal pain. Day 4 of treatment, daytime blood HGB 77 g/L. Bilateral renal vascular ultrasound: bilateral renal artery blood flow velocity was reduced. The abdominal pain of the above symptoms recurred at night, BP was 120/80 mmHg, and no positive signs were found on abdominal examination. No abnormality was found in the vertical abdominal plain film. Blood routine examination: HGB 53 g/L, Plasma D dimer 2 515 μg/L, amylase in hematuria was normal, the stool occult blood was negative. Abdominal computed tomography (CT): normal structure of right adrenal gland disappeared, irregular mass shadow could be seen in adrenal region, CT value was about 50 HU. Morphological density of left adrenal gland was not abnormal. The retroperitoneum descended along the inferior vena cava to the right iliac blood vessel and showed a bolus shadow. The density of some segments increased. The lesion involved the right renal periphery and reached the left side of abdominal aorta. Most lesions surrounded the inferior vena cava, the right renal vein and part of the small intestine. The boundary between the upper lesion and the vena cava was unclear. Iodinecontaining contrast agent was taken orally. No sign of contrast agent overflowing was found in the abdominal cavity. Hematoma and exudative changes were considered in retroperitoneum. CONCLUSION of contrast-enhanced ultrasound of blood vessels: The retroperitoneal inferior vena cava (volume 3.5 cm×3.5 cm×1.5 cm) was hypoechoic and had no blood flow lesion. The adrenal gland had a high possibility of origin. Left renal vein thrombosis extended to inferior vena cava. According to the above data, it was analyzed that the cause of retroperitoneal hematoma of the patient was left adrenal vein thrombosis caused by hypercoagulable state, which led to vascular rupture and hemorrhage caused by increased vascular pressure in adrenal gland. Therefore, on the basis of continuing to actively treat the primary disease, and on the basis of dynamic observation of no active hemorrhage for 3 days, the anticoagulant therapy was continued with 10 mg/d of apixaban. Clinical symptoms were gradually eased, HGB did not decrease. Two weeks later, the ultrasonic examination showed that the irregular cluster hypoechoic range behind the inferior vena cava was significantly smaller than that before (1.8 cm×1.2 cm×0.7 cm). Abdominal CT examination after 1 month showed that there was no abnormal morphological density of bilateral adrenal glands and basic absorption of retroperitoneal exudation. Adrenal hemorrhage is uncommon. SLE with adrenal hemorrhage is rarer. In SLE patients, especially those complicated with APS, if abdominal pain accompanied by HGB decrease occurs, except after gastrointestinal hemorrhage, the possibility of adrenal hemorrhage should be warned.

Abdominal tuberculosis.

Forty-two cases of abdominal tuberculosis seen between June 1984 and June 1988 at Amiri Hospital in Kuwait were reviewed retrospectively. The clinical diagnosis was correct in only 35%. Nine patients presented as an emergency, but in none was a diagnosis of tuberculosis considered. Abdominal pain and tenderness were the commonest clinical findings; "doughy abdomen" and a mass in right iliac fossa were uncommon. Thus, symptoms were vague, signs nonspecific and investigations nonpathognomonic. In spite of this, abdominal tuberculosis should be considered in any patient who has obscure abdominal symptoms, weight loss and lethargy. Laparoscopy and colonoscopy with biopsy for histologic and bacteriologic study led to a definitive diagnosis in 66% of cases, obviating the need for exploratory laparotomy in many. Histologic examination was the surest way to establish the diagnosis.

Pneumatosis intestinalis associated with Henoch-Schönlein purpura.

Henoch-Schönlein purpura (HSP) is the most common vasculitis in children. It is a disorder of the inflammatory cascade leading to immunoglobulin A deposition and leukocytoclastic vasculitis of small vessels of skin, kidneys, joints, and gastrointestinal (GI) tract. A wide variety of GI manifestations are seen in ∼50% to 75% of patients with HSP. Diffuse colicky abdominal pain is the most common GI symptom. The small bowel is the most frequently involved GI site. Intussusception is rare but is the most common surgical complication. We report the case of a 2-year-old girl with a 5-day history of abdominal pain followed by a palpable purpuric rash. Her urinalysis, complete blood cell count, and tests of renal function were normal. An acute abdominal series was unremarkable initially, and abdominal ultrasound imaging showed ascites and thickened small bowel loops. She was diagnosed with HSP. The abdominal pain worsened, and an abdominal computed tomography scan demonstrated distal small bowel wall thickening and pneumatosis intestinalis in the descending colon. She was started on total parenteral nutrition and antibiotics and placed on bowel rest. She was given 2 mg/kg of intravenous immunoglobulin. Her abdominal pain gradually improved over the next week, and a repeat computed tomography scan showed significant improvement of the small bowel wall thickening and pneumatosis. The purpuric rash improved, and her abdominal pain resolved. We report a case of HSP and pneumatosis intestinalis, an association that has not been reported previously.

Abdominal Angina -- History and Physical

The typical clinical presentation of abdominal angina is severe pain out of proportion to the physical exam. The patient usually complains of severe abdominal pain that starts after eating a meal. In most cases, the pain gradually subsides after a few hours. Because the pain is so severe, most people develop a fear of eating and hence lose weight. One should always ask about a history of smoking, claudication, and hyperlipidemia. On physical exam, marked weight loss is obvious. The abdomen is often soft, and there are no peritoneal signs. An abdominal bruit may be heard in some patients. One may also find features of peripheral vascular disease with diminished pulses in the leg. The digital rectal exam is usually guaiac negative.

Chronic hip pain in a boy with mental retardation and cerebral palsy.

Jonny is a 13 year old boy with spastic quadriparesis and severe mental retardation following Haemophilus influenza type B (HIB) meningitis at 2-months of age. Signs of meningitis started on the evening of his 2-month immunizations that included the HIB vaccine. He presented to his pediatrician with left hip pain that occurred intermittently for a few years and more frequently in the past six months. His parents initially attributed the pain to whizzing around the back yard in a motorized wheelchair. An earlier evaluation of hip pain led to bilateral femoral osteotomies for hip dysplasia. Obesity, associated with inactivity and a tendency to consume fatty foods, complicates Jonny's disabilities. His only activity is a modest amount of physical therapy at school and "floor time" for about one hour each day at home. In the office of his pediatrician, Jonny is friendly, smiling, and verbalizing a few words with his limited expressive vocabulary. He is resistant to a hip examination and grimaces with manipulation of his left hip. Spasticity of the left leg appears increased compared to previous examinations. He has nonpitting edema of his lower legs and feet, a cryptorchid left testicle, and a somewhat tender left inguinal area. Jonny lives with his mother and father in a small house on a busy street less than one-half mile from the pediatrician's office. Jonny's pediatrician often sees him in his wheelchair, accompanied by his mother or grandmother, and waves or stops to chat. He has van services to school, and there is a Hoyer lift in the home, but his parents do not own a van. Recently, Jonny's father finds it more difficult to lift him. The family has also been challenged by the mental health problems of Jonny's two older brothers, and a serious eye injury suffered by his middle brother in a motor-vehicle accident. Jonny's pediatrician has cared for him and his two brothers since birth. Although the parents continue to believe that the HIB vaccine caused his catastrophic illness, they remain with the pediatrician. In general, they are satisfied with the individualized educational plan at a local public school. When he was 6.5 years old, Jonny's school aid reported that he attempted to touch her in the genital area. The pediatrician attended the meeting to review this incident and successfully advocated for Jonny by pointing out that this was an isolated incident; it did not occur again. At 6 years old Jonny functioned in the 1.5-2.5 year old range with motor skills in the 6-12 month level according to the Bayley Scales of Infant Development and the Vineland Adaptive Behavior Scales. In the past a neurologist and a physiatrist saw Jonny, but both of these individuals moved from the community. He had prior evaluations at a children's orthopedic clinic at a small community hospital and at the local Shriner's hospital. He had a tonsillectomy and adenoidectomy at 7 years old. He is currently treated for constipation and receives dental care at a clinic for people with disabilities. His pediatrician has always respected the parents for their care and obvious love for their disabled child. However, parental resistance to addressing major issues such as obesity has frustrated his pediatrician. When the pediatrician suggested that Jonny was eligible for the state's managed care program, which would convert Medicaid coverage to a state sponsored program with more extensive services and case management, Jonny's mother repeatedly said that she would "think it over." At the current visit, the pediatrician recommended an adjustment of Jonny's wheelchair, a hip x-ray, a referral to Shriner's Hospital, and an appointment with a pediatric surgeon to address the undescended testicle and possible hernia. Jonny's mother mentioned that he had been to Shriner's Hospital for hip pain two years earlier but was told nothing could be done "because nothing was wrong with his bone." The hip x-ray was normal as well as a complete blood count and a C-reactive protein. The pediatric surgeon did not find a hernia and deferred treatment of the cryptorchid testicle. His parents contacted the wheelchair company to arrange adjustments. The pediatrician called the medical director at the Shriner's Hospital to discuss Jonny's case, but 2 months after the initial visit, the parents had not arranged for an appointment at the Shriner's Hospital. Jonny's hip pain persisted. The pediatrician now wonders how he can more effectively address Jonny's current problems and improve overall care for him and his family.

Dengue fever mimicking acute appendicitis.

We report 12 patients [5 males, mean age 28 years (SD 4.6)] presenting with clinical features suggestive of acute appendicitis who were later diagnosed as having dengue fever (DF). Seven were admitted to hospital by surgeons and then referred to physicians due to thrombocytopenia (one of them following appendicectomy). Five were admitted to medical wards and then referred to surgeons due to abdominal pain. The mean time from onset of fever to abdominal pain was 2.2 d (SD 0.9). Clinical features included: right iliac fossa tenderness in 12 patients, rebound tenderness in nine, vomiting in nine, erythematous rash in eight, arthralgia/myalgia in eight, headache in six, diarrhea in three and palatal petechiae in three. All patients had C-reactive protein <12mg/l, and DF was confirmed serologically. Leucocytopenia and thrombocytopenia occurred by the third or fourth day of illness in all patients. Seven had free fluid around the appendix on abdominal ultrasound. The mean duration of abdominal symptoms and signs was 1.8 d (SD 1.3). DF may present with features suggestive of acute appendicitis in dengue-endemic areas. A carefully obtained history, clinical examination and a full blood count done on the third or fourth day of illness may help to differentiate DF from acute bacterial appendicitis.


They refer to a concept that has emerged relatively recently and is not present in all clinical guidelines as uncomplicated symptomatic diverticular disease. In these cases, the therapeutic trial with rifaximin is recommended, being the true number 1. The absence of acute phase reactants in the CBC suggests that she does not have acute diverticulitis at the time of consultation that would lead us to request an imaging test to rule it out.

They refer to a concept that has emerged relatively recently and is not present in all clinical guidelines as uncomplicated symptomatic diverticular disease. In these cases, the therapeutic trial with rifaximin is recommended, being [HIDDEN]. The absence of acute phase reactants in the CBC suggests that she does not have acute diverticulitis at the time of consultation that would lead us to request an imaging test to rule it out.

83-year-old male who consults for a recurrent picture of abdominal pain in the left iliac fossa, accompanied by diarrhea of up to 6 stools per day without pathological products, of 10-15 days of evolution. No fever or general condition was reported. A recent blood test showed no leukocytosis and a negative fecal occult blood test. On examination there is mild pain on palpation of the left iliac fossa without peritoneal irritation. He had a colonoscopy three years ago in which diverticula were reported along the entire colon, more numerous in the left colon, with no other associated lesions. Which of the following would be the best approach to follow?

Refer to surgery to evaluate sigmoidectomy.

Colonoscopy

Fecal occult blood is a quick test which can be done to test for microscopic traces of blood in the stool. A positive test is almost always an indication to do a colonoscopy. In most cases the positive result is just due to hemorrhoids; however, it can also be due to diverticulosis, inflammatory bowel disease (Crohn's disease, ulcerative colitis), colon cancer, or polyps. Colonic polypectomy has become a routine part of colonoscopy, allowing quick and simple removal of polyps during the procedure, without invasive surgery. Colon cancer screening Colonoscopy is one of the colorectal cancer screening tests available to people in the US who are 45 years of age and older. The other screening tests include flexible sigmoidoscopy, double-contrast barium enema, computed tomographic (CT) colongraphy (virtual colonoscopy), guaiac-based fecal occult blood test (gFOBT), fecal immunochemical test (FIT), and multitarget stool DNA screening test (Cologuard).

Colitis

More severe symptoms may include: shortness of breath, a fast or irregular heartbeat and fever. Other less common or rare non-specific symptoms that may accompany colitis include: arthritis, mouth ulcers, painful, red and swollen skin and irritated, bloodshot eyes. Signs seen on colonoscopy include: colonic mucosal erythema (redness of the colon's inner surface), ulcerations and hemorrhage. Diagnosis Symptoms suggestive of colitis are worked-up by obtaining the medical history, a physical examination and laboratory tests (CBC, electrolytes, stool culture and sensitivity, stool ova and parasites et cetera). Additional tests may include medical imaging (e.g. abdominal computed tomography, abdominal X-rays) and an examination with a camera inserted into the rectum (sigmoidoscopy, colonoscopy).

Diverticulitis

Signs and symptoms Diverticulitis typically presents with lower quadrant abdominal pain of a sudden onset. Patients commonly have elevated C-reactive protein and a high white blood cell count. In North America and Europe the abdominal pain is usually on the left lower side (sigmoid colon), while in Asia it is usually on the right (ascending colon). There may also be fever, nausea, diarrhea or constipation, and blood in the stool. Complications

InternalMed_Harrison

APPROACH TO THE PATIENT: The decision to evaluate acute diarrhea depends on its severity and duration and on various host factors (Fig. 55-2). Most episodes of acute diarrhea are mild and self-limited and do not justify the cost and potential morbidity rate of diagnostic or pharmacologic interventions. Indications for evaluation include profuse diarrhea with dehydration, grossly bloody stools, fever ≥38.5°C (≥101°F), duration >48 h without improvement, recent antibiotic use, new community outbreaks, associated severe abdominal pain in patients >50 years, and elderly (≥70 years) or immunocompromised patients. In some cases of moderately severe febrile diarrhea associated with fecal leukocytes (or increased fecal levels of the leukocyte proteins, such as calprotectin) or with gross blood, a diagnostic evaluation might be avoided in favor of an empirical antibiotic trial (see below).

InternalMed_Harrison

Presentation, Evaluation, and Staging of Diverticulitis Acute uncomplicated diverticulitis characteristically presents with fever, anorexia, left lower quadrant abdominal pain, and obstipation (Table 353-1). In <25% of cases, patients may present with generalized peritonitis indicating the presence of a diverticular perforation. If a pericolonic abscess has formed, the patient may have abdominal distention and signs of localized peritonitis. Laboratory investigations will demonstrate a leukocytosis. Rarely, a patient may present with an air-fluid level in the left lower quadrant on plain abdominal film. This is a giant diverticulum of the sigmoid colon and is managed with resection to avoid impending perforation.

Diverticulosis

Diverticulitis Infection of a diverticulum can result in diverticulitis. A recent study found that it happens only about 4% of the time. That contradicts the prevailing thinking that 10% to 25% of people with diverticulosis go on to develop diverticulitis. Tears in the colon leading to bleeding or perforations may occur; intestinal obstruction may occur (constipation or diarrhea does not rule this possibility out); and peritonitis, abscess formation, retroperitoneal fibrosis, sepsis, and fistula formation are also possible occurrences. Rarely, an enterolith may form. Infection of a diverticulum often occurs as a result of stool collecting in a diverticulum. It is defined as diverticular disease with signs and symptoms of diverticular inflammation. Clinical features of acute diverticulitis include constant abdominal pain, localized abdominal tenderness in the left lower quadrant of the abdomen, nausea, vomiting, constipation or diarrhea, fever and leukocytosis.

Colon Cancer -- History and Physical

Most all CRC will present by diagnostic colonoscopy for suspicious signs and symptoms (80%), asymptomatic, routine screening (11%), or incidental finding at an acute abdomen emergent admission (7%). Patients diagnosed with routine cancer screening are frequently earlier stage compared to advanced disease of incidental surgical findings. Diagnostic colonoscopy’s triggers are blood per rectum (37%), abdominal pain (34%) and anemia (23%). Most common indications of emergency surgery are an obstruction (57%), peritonitis (25%) and perforation (18%). Tumor location on clinical presentation can be separated on left-sided with more changes in bowel habits and hematochezia, and right-sided with obscured anemia impacting on late stage at diagnosis. Late presentation with metastatic disease at diagnosis will depend on the symptoms at the organ-affected by the route of spread; to the liver via the portal system, to lungs via the inferior vena cava, to supraclavicular adenopathy via lymphatic or to neighbor structures by contiguous invasion. The provider should perform a thorough physical examination for signs of ascites, hepatomegaly, and lymphadenopathy.  A comprehensive family history is of great relevance to identify familial clusters and inherent patterns that would alter surveillance and therapy on the high-risk patient.

Valentino's syndrome

When patients present with right lower quadrant pain their vitals, such as blood pressure, pulse, oxygen saturation, and temperature, are monitored. A complete blood count (CBC) is done to determine the number of white blood cells present in the patient’s blood and test for leukocytosis, a condition in which the white blood cells are above the normal levels. Abdominal examination usually discloses generalized tenderness, rebound tenderness in the right iliac fossa, guarding, and rigidity. A physical examination that is positive for abdominal pain categorized as McBurney’s point tenderness, Von Blumberg's sign, Rovsing's sign, Dunphy's sign and Psoas sign, could all indicate acute appendicitis and lead to misdiagnosis. However, these physical examination findings are also present in Valentino’s Syndrome.

Appendicitis -- History and Physical -- Uncommon Presentations

Several practical scores have been defined to facilitate the prompt diagnosis of acute appendicitis, mainly based on the history and physical examination, accompanied by laboratory tests and imaging measures, including abdominal ultrasonography. Accordingly, evaluation of patients with suspicious signs and symptoms suggestive of acute appendicitis has been widely undertaken with Alvarado criteria since 1986. The highest score among Alvarado criteria is allocated to the tenderness in the right iliac fossa, leukocytosis, and each of the other predicted symptoms, including migratory right iliac fossa pain, nausea, and or vomiting, and anorexia, hold one score. Moreover, positive findings in the remaining indexes of physical examination, including fever and rebound tenderness in the right iliac fossa, would hold a similar score of one. [13]

Descending colon

Colon cancer Cancer of the descending colon is a serious disease. A person can have colon cancer yet have no symptoms in the early stages. As such, regular colorectal examinations or fecal occult blood testing are necessary for catching the disease in its early stages. However, there are some signs that can indicate colon cancer; they include abrupt changes in bowel habits, bleeding from the rectum, black stools, frequent constipation, and mucus in the stools. Treatment options depend on the stage of the cancer and the overall health of the patient. See also Colonoscopy Ascending colon References External links Lotti M. Anatomy in relation to left colectomy - "The large intestine." Large intestine

InternalMed_Harrison

Fulminant (rapidly progressive and severe) CDI presents the most difficult treatment challenge. Patients with fulminant disease often do not have diarrhea, and their illness mimics an acute surgical abdomen. Sepsis (hypotension, fever, tachycardia, leukocytosis) may result from severe CDI. An acute abdomen (with or without toxic megacolon) may include signs of obstruction, ileus, colon-wall thickening and ascites on abdominal CT, and peripheral-blood leukocytosis (≥20,000 WBCs/μL). With or without diarrhea, the differential diagnosis of an acute abdomen, sepsis, or toxic megacolon should include CDI if the patient has received antibiotics in the past 2 months. Cautious sigmoidoscopy or colonoscopy to visualize PMC and abdominal CT are the best diagnostic tests in patients without diarrhea.

Diverticulosis of the colon: a report of two cases.

Diverticula are bulging pouch-like herniations in the wall of the hollow organ anywhere in the gastrointestinal tract from the oesophagus to the colon. Diverticula are thought to occur more commonly in the colon than in any other segment of the gastrointestinal tract. It may be asymptomatic or complicated by diverticulitis (diverticular inflammation), bleeding, or perforation with peritonitis. It could be potentially life threatening. It was thought to be rare in this part of the world, but is increasingly diagnosed with the advent of modern imaging techniques and colonoscopy. Two cases of colonic diverticula discovered during colonoscopy were highlighted. Case 1--This patient was a 79-year old traditional ruler who presented with 2 months history of progressive left- sided abdominal pain, dull in nature and sometimes colicky but non-radiating. There was no known aggravating or relieving factors. There was associated history of chronic constipation dating back to over 15 years relieved with use of laxatives. There was no diarrhoea, vomiting or haematochezia. He had no history of previous surgeries. Physical examination showed mild tenderness at the left iliac fossa. Digital rectal examination was normal. Plain abdominal x-ray and abdomino-pelvic ultrasound scan showed no abnormalities. Colonoscopy revealed multiple diverticula with diverticulitis at the descending and sigmoid colon 40 cm-60 cm from the anal verge. Case 2--This patient is a 64-year old retired military officer who presented with constipation of 5 years and rectal bleeding of 10 months. Pre-morbid bowel habit was 1-2 bowel motions per day but now once in 2 days. Constipation was characterized by recurrent passage of hard pellet-like stools. This became associated with passage of fresh blood in the stool 10 months ago, and anal pain. Volume of blood was about 5 mls per episode, and this occurred only when stool was hard. The anal pain was sometimes severe enough to prevent the patient from sitting comfortably on both buttocks. There was no weight loss or constipation alternating with diarrhoea. He had no history of any chronic medical illness. Colonoscopy revealed anal fissure, internal haemorrhoids, and multiple diverticula in the sigmoid and descending colon. Both patients are being managed conservatively with dietary advice and antibiotics, and still being followed up in the clinic. Reports of colonic diverticula with diverticulitis in this part of the world are few. This is the first report of colonic diverticulosis from Ilorin.

Fever of unknown origin as the first manifestation of colonic pathology.

Fever of unknown origin (FUO) is an entity caused by more than 200 diseases. Haematologic neoplasms are the most common malignant cause of FUO. Fever as a first symptom of colonic tumour pathology, both benign and malignant, is a rare form of presentation. Our work is a descriptive study of a series of 23 patients with colonic tumoral pathology who presented with fever of unknown origin. The mean age was 67.6 years; 56.5% of patients were men and 43.5% were women. Primary malignant neoplasia was the most common diagnosis. Blood cultures were positive in 45% of the samples. Coagulase-negative staphylococci were the most common cause of bacteraemia. Nine of 10 faecal occult blood tests performed were positive. Fever secondary to colon neoplasms, both benign and malignant, usually presents with a bacteraemic pattern, with positive results for blood-culture tests in a high percentage of cases.

Brodifacoum

In another case reported in 2013, a 48-year-old female patient reported 4 days of mild dyspnea, dry cough, bilateral popliteal fossae pain, and diffuse upper abdominal pain. She had no history of liver disease or alcohol or illicit substance abuse. Initial physical examination was remarkable only for mildly pale conjunctivae and mild abdominal tenderness and pain in the left popliteal fossa. A complete blood count and complete metabolic panel were normal. Prothrombin time (PT) was above 100 s, partial thromboplastin time (PTT) was above 200 s and international normalized ratio (INR) was reported as above 12.0. Urinalysis revealed hematuria (blood in the urine). Venous Doppler ultrasound of lower extremities demonstrated left popliteal vein thrombosis. Computed tomography scan of the abdomen demonstrated transmural hematoma, and a fecal occult blood test was positive. A full anticoagulant work-up showed critical reduction of vitamin K-dependent factors II, VII, IX, and X. PT and PTT

[Comparison of symptoms and clinical and laboratory findings in the first and last weeks of typhoid fever].

In this study we examined the clinical and laboratory findings of 80 in-patients. There is an important difference between sexes (p greater than 0.05). Comparison of ages showed that 7-30 age is more vulnerable than the older group. We found clinical symptoms of fever, chills, headache, abdominal pain, disturbances in bowel function, nausea, vomiting, anorexia, and lassitude in the first two weeks more frequently when compared with the 3rd, 4th, 5th weeks of illness (p less than 0.001). Where physical finding of rose spots, discordant pulse rate are important in the first two weeks (p less than 0.001). Abdominal discomfort is an important symptom both in the first two and in the last three weeks (% 40.3 and % 36 respectively). Hepatomegaly and splenomegaly, were found more frequently in the last three weeks. According to laboratory findings of anemia, leukopenia, increased erythrocyte sedimentation rate and positive blood and feces cultures there is no important difference between the first two and last three weeks (p greater than 0.05). Increase in polynuclear leucocytes is important for the first two weeks, and increase in lymphocytes is important in the last three weeks (p less than 0.001). Positivity of group agglutination tests is 57%, in the first two weeks and 83% in the last three weeks. This difference is found to be important.

Appendicitis

Rovsing's sign: Pain in the lower right abdominal quadrant with continuous deep palpation starting from the left iliac fossa upwards (counterclockwise along the colon). The thought is there will be increased pressure around the appendix by pushing bowel contents and air toward the ileocaecal valve provoking right-sided abdominal pain. Sitkovskiy (Rosenstein)'s sign: Increased pain in the right iliac region as the person is being examined lies on their left side. Perman's sign: In acute appendicitis palpation in the left iliac fossa may produce pain in the right iliac fossa.Emil Samuel Perman 1856-1946 "About the indications for surgery in appendicitis and an account of cases of Sabbatsberg Hospital in Hygiea 1904

[Value of admission for observation in the management of acute abdominal right iliac fossa pain. Prospective study of 205 cases].

Because of the potential severity of acute appendicitis, many authors recommend the broad use of appendectomy. In this case, 15 to 20% of appendectomies are ultimately found to have been unnecessary. Hospital observation with repeated clinical and laboratory exams can be useful for patients with atypical clinical presentation. This paper assesses our approach, in which some patients with pain in the right iliac fossa (RIF) are admitted for observation before a decision about appendectomy. All patients (205 cases) admitted from March 2002 through February 2003 for acute abdominal pain of the RIF were included in this prospective study. The 120 women and 85 men (sex ratio=0.7) had a mean age of 27 years. We classified the patients into 3 groups: those who had an emergency appendectomy, those who had surgery after an observation period, and those discharged without appendectomy after observation. The first group included 110 patients: 63% had a (rectal) temperature greater than 38 degrees C; 44% had guarding of the RIF and 87% elevated white blood cell counts (>10000/mm3). At surgery, appendicitis was diagnosed in 92%. After a mean delay of 36 hours of observation, 50 of the patients in the second group underwent surgery: 44% with (rectal) temperature > 38 degrees C, RIF guarding in 8%, and elevated white blood cell count (>10000/mm3) in 74%. In this group, 94% were diagnosed with appendicitis during surgery. Forty-five patients were discharged without surgery after 36 hours of observation. In this study, pain and RIF guarding, associated with temperature greater than 38 degrees C and elevated white blood cell counts, were predictive of appendicitis in 96% of cases. Admission for observation of patients with atypical presentation avoided 45 unnecessary appendectomies (22%).

Colonoscopy

Colonoscopy is similar to sigmoidoscopy—the difference being related to which parts of the colon each can examine. A colonoscopy allows an examination of the entire colon (1200–1500mm in length). A sigmoidoscopy allows an examination of the distal portion (about 600mm) of the colon, which may be sufficient because benefits to cancer survival of colonoscopy have been limited to the detection of lesions in the distal portion of the colon. A sigmoidoscopy is often used as a screening procedure for a full colonoscopy, often done in conjunction with a fecal occult blood test (FOBT). About 5% of these screened patients are referred to colonoscopy.

Ovarian abscess as a complication of assisted reproduction techniques: a case report.

AMP makes true great strides these last decades. Logically some complications were noticed even due to ovarian puncture such as hemorrhage, perforation or infection. The aim of this report is to try, through a review of literature, to draw the attention of physicians to a rare entity, ovarian abscess after follicle aspiration for in-vitro fertilization, and to means of prevention. We report a 38-year-old woman who was plainting from lower abdominal pain located in the left iliac fossa one month after failed IVF trial. The pain was associated with fever and vomiting. The patient's past medical history involves 2 myomectomys (2003-2007). On admission, her temperature was 38.9 degrees C and her blood pressure was 90/60 mm Hg. Physical examination found nondistended abdomen. Tenderness to deep palpation in the left lower quadrant, without peritoneal signs, was detected. No masses were palpated. Mild tenderness in the left cul-de-sac was found. A full blood count showed a white cell count of 17,500 cells/mm3 with 84.5% polymorph nuclear cells, CRP 173 mg/dl. Pelvic ultrasound shows a left latero uterine mass; right ovary and the uterus are unremarkable; there was no free abdominal fluid. The laparotomy was performed 24 hours later and a left ovarian abscess was found. The treatment was conservative. Antibiotics were associated during 15 days. The clinical evolution was satisfying. The ovarian puncture might be technically difficult, incomplete, and even impossible which exposes to a greater infection risk. An ultrasound evaluation of ovarian accessibility is necessary before starting an IVF attempt, especially in case of overweight or history of abdominal or pelvic surgery, endometriosis, tubal abnormalities or myomas. The treatment is based on surgery and antibiotics.

InternalMed_Harrison

The diagnostic yield of echocardiography, sinus radiography, radiologic or endoscopic evaluation of the gastrointestinal tract, and bronchoscopy is very low in the absence of PDCs. Therefore, these tests should not be used as screening procedures. After identification of all PDCs retrieved from the history, physical examination, and obligatory tests, a limited list of the most probable diagnoses should be made. Since most investigations are helpful only for patients who have PDCs for the diagnoses sought, further diagnostic procedures should be limited to specific investigations aimed at confirming or excluding diseases on this list. In FUO, the Fever ˜38.3° C (101° F) and illness lasting ˜3 weeks and no known immunocompromised state History and physical examination Stop antibiotic treatment and glucocorticoids Obligatory investigations:

Case reports of adult colo-colonic intussusception.

Adult colo-colonic intussusception is a rare abnormality and it may pose a diagnostic challenge. To report two cases of adult colo-colonic intussusception with benign lesion as the lead points. The Clinical records of the two patients containing the management details were retrieved and reviewed. The 1st case was a 60 year old man presenting with a year history of recurrent left abdominal pain a two week history of fullness left upper and lower abdomen. Examination showed an 8cm by 6 cm mass in the left hypochondrium continuing with another 16cm by 8 cm mass spanning the left lumbar and left iliac fossa. Abdominal ultrasound scan showed a huge mixed echogenic mass in the central abdomen spanning the left hypochondriac, left lumber and suprapubic regions. He had exploratory laparotomy which revealed cob-cobonic intussusception involving the ascending colon up to sigmoid colon. He had subtotal colectomy done. The lead point was a hamartomatous polyp The 2nd case was a 35 year old man with a two month history of recurrent abdominal pain and haematochezia, a month history change in bowel habit and five day history of abdominal distension. Examination showed distended abdomen with generalised tenderness. There was a firm mass in the left hypochondrium extending to the left iliac fossa. Abdominal ultrasound scan confirm intussusception: Exploratory laparotomy showed perforation of transverse colon at the neck of cob-colonic intussusception involving the distal third of the transverse colon to the rectum. He had extended left hernicolectomy and Devine colostomy done. He died 36 h6urs post operation. The lead point was an inflammatory polyp. Adult colo-colonic intussusception is an uncommon disease which may not present in a typical feature of intussusception as occur in children thus posing diagnostic dilemma. High index of suspicion with radiological investigation will serve to aid rapid and accurate diagnosis.

InternalMed_Harrison

In patients with unexplained fever after all of the above procedures, the last step in the diagnostic workup—with only a marginal diagnostic yield—comes at an extraordinarily high cost in terms of both expense and discomfort for the patient. Repetition of a thorough history-taking and physical examination and review of laboratory results and imaging studies (including those from other hospitals) are recommended. Diagnostic delay often results from a failure to recognize PDCs in the available information. In these patients with persisting FUO, waiting for new PDCs to appear probably is better than ordering more screening investigations. Only when a patient’s condition deteriorates without providing new PDCs should a further diagnostic workup be performed.

Postpolypectomy coagulation syndrome

Postpolypectomy coagulation syndrome (Postpolypectomy syndrome or PPCS) is a condition that occurs following colonoscopy with electrocautery polypectomy, which results in a burn injury to the wall of the gastrointestinal tract. The condition results in abdominal pain, fever, elevated white blood cell count and elevated serum C-reactive protein. Signs and symptoms PPCS causes abdominal pain and fever. The condition usually onsets within 1–5 days after colonoscopy with polypectomy using electrocautery. Physical examination may show evidence of peritonitis. Etiology PPCS is caused by an electrocautery-induced injury to the wall of the colon that occurs during removal of colon polyps. PPCS occurs when the electric current extends beyond the mucosa, entering the muscularis propria and serosa, resulting in a full thickness (transmural) burn injury. The transmural burn results in localized inflammation of the peritoneum (peritonitis).

Segmental colitis associated with diverticulosis: systematic evaluation of 486 cases with meta-analysis.

Segmental colitis associated with colonic diverticulosis is a new and emerging entity. We systematically evaluated 486 cases of this entity and performed qualitative meta-analysis on this information. This diagnosis was made on a 64-year old man by colonoscopic biopsy. His clinical symptoms included hematochezia and crampy lower abdominal pain. PubMed Search using terms such as segmental colitis, colitis associated with diverticulosis was made without language or time barrier. Additional papers were manually added from the reference lists of key articles. Qualitative meta-analysis was done using the well-established methods of qualitative research, e.g. diagramming, theme repetition without serious contradiction, theme saturation and investigator reflexivity. To facilitate qualitative meta-analysis, summary sheets of publications were created. This search produced 486 cases with this entity. The prevalence in patients with diverticulosis is 0.3% to 1.3%. There were 58.7% men. The mean age was 63.6 (range 26-87) years. The most common presenting symptoms were rectal bleeding, diarrhea and abdominal pain. Fever, leucocytosis and rectal involvement were characteristically absent. Endoscopic appearance and histology may resemble ulcerative colitis. Many of these patients have a benign course with spontaneous resolution or may respond to 5-aminosalucylates or steroids. This is a new and emerging entity. There is male predominance and it occurs in relatively elderly patients. It can be distinguished from acute diverticulitis by clinical, endoscopic and histological features. Most have a benign course.

Colon Diverticulitis -- History and Physical

Laboratory findings include leukocytosis and possibly elevated inflammatory markers. [15] Those patients with complicated diverticulitis may present with signs of sepsis and physical findings consistent with peritonitis. Physical findings may include abdominal tenderness, abdominal distension, a tender mass in the abdomen, absent bowel sounds, and findings related to fistula formation. The presence of fecaluria and pneumaturia must alert the clinician to the possibility of a colovesical fistula.

Large intestine

Colonoscopy is similar to sigmoidoscopy—the difference being related to which parts of the colon each can examine. A colonoscopy allows an examination of the entire colon (1200–1500 mm in length). A sigmoidoscopy allows an examination of the distal portion (about 600 mm) of the colon, which may be sufficient because benefits to cancer survival of colonoscopy have been limited to the detection of lesions in the distal portion of the colon. A sigmoidoscopy is often used as a screening procedure for a full colonoscopy, often done in conjunction with a stool-based test such as a fecal occult blood test (FOBT), fecal immunochemical test (FIT), or multi-target stool DNA test (Cologuard) or blood-based test, SEPT9 DNA methylation test (Epi proColon). About 5% of these screened patients are referred to colonoscopy.

[Acute appendicitis. A clinicopathological analysis of 200 cases].

a) to carry out a prospective study of 200 cases of acute appendicitis in adult patients; b) to correlate clinical, laboratory, radiological, and pathological findings. clinical data were collected from all patients; every patient had hematic biometry, urine exam (UE), abdominal radiography, an histopathological study appendix. the patients were 98 males and 102 females; 66.5% were between 15 and 25 years old. All patients had abdominal pain, 56.5% nausea and vomit, 49% fever, 10.5% diarrhea, and 6% urinary symptoms. Post-operatory complications were seen in 24.5%. Leucocytosis greater than 10,000 was found in 82.5%, some alteration of UE in 45%, and abnormal radiography in 56.5%. Histopathological study showed simple appendicitis in 16.5%, hemorrhagic in 8%, purulent in 22%, hemo-purulent in 30.5%, an perforated in 21%. the diagnosis of appendicitis is basically a clinical one, since 17.5% showed normal white-cell count, and 43.5% normal radiography.

An unusual abdominal mass in a renal transplant recipient.

Renal transplant recipients are at increased risk of malignancy and infection. We present the case of a 72-year-old-man with recurrent bladder carcinoma, abdominal aortic aneurysm repair, and end-stage renal failure due to renovascular disease. He received a cadaveric renal allograft into his left iliac fossa, was given cyclosporin A, azathioprine, and prednisolone triple therapy immunosuppression, and had no rejection episodes. He presented four years post-transplantation with a two-year history of intermittent sweats and fevers. Previous episodes had been investigated with no firm diagnosis made. This time he had right iliac fossa pain of three weeks' duration. Examination revealed a tender mass. Investigations showed unchanged graft function, but elevated inflammatory indices. Ultrasonography and computed tomography detailed an infiltrating mass associated with the sigmoid colon, which colonoscopy failed to visualise. At laparotomy a 6-cm tumor was removed, with adherent sigmoid colon and bladder dome. Macroscopically the mass was an abscess, and microscopy found acute and chronic inflammatory giant cells and fibrillary masses suggestive of actinomycosis, with no malignancy. The patient recovered uneventfully on antibiotics. At six months' follow-up, examination, inflammatory markers, and radiographic imaging showed no evidence of recurrence. Twelve months later the patient died of rupture of his proximal abdominal aorta. There was no evidence of recurrence at postmortem examination. We conclude with a brief review of actinomycosis in transplant recipients.

InternalMed_Harrison

Presentation and Evaluation Perianal pain and fever are the hallmarks of an abscess. Patients may have difficulty voiding and have blood in the stool. A prostatic abscess may present with similar complaints, including dysuria. Patients with a prostatic abscess will often have a history of recurrent sexually transmitted diseases. On physical examination, a large fluctuant area is usually readily visible. Routine laboratory evaluation shows an elevated white blood cell count. Diagnostic procedures are rarely necessary unless evaluating a recurrent abscess. A CT scan or MRI has an accuracy of 80% in determining incomplete drainage. If there is a concern about the presence of inflammatory bowel disease, a rigid or flexible sigmoidoscopic examination may be done at the time of drainage to evaluate for inflammation within the rectosigmoid region. A more complete evaluation for Crohn’s disease would include a full colonoscopy and small-bowel series.

Succesful [Successful] endovascular repair of an abdominal mycotic aneurysm. A case report.

A 73-year-old man was admitted to the emergency department presenting with cramping pain in the left iliac fossa that had persisted for ten days, with diarrhoea and dysuria. A recent onset of high fever had urged him to the hospital. A routine blood sample showed a leukocytosis of 11.9 x 10(3)/mm(3) and an elevated CRP of 16 mg/dl. Haemocultures and a urine sample were taken. A colonoscopy and ultrasound showed no abnormalities. The urine culture contained salmonella enteritidis. On day 5 a CT scan of the abdomen was performed. This showed a saccular aneurysm of the abdominal aorta, approximately 2 cm in length, with clear signs of a contained rupture. An urgent EVAR procedure was performed. An Excluder bifurcation-endoprosthesis was placed under antibiotic coverage. Control CT scan showed a thrombosis of the aneurysm and a type II endoleakage. The endoleakage spontaneously resolved within 3 months. The patient was kept on antibiotics (levofloxacine) for 4 months. We suggest that the use of an endoprosthesis could be a good and safe alternative for the repair of infrarenal mycotic aorta aneurysm.

Diverticulosis -- History and Physical

Acute diverticulitis (e.g., inflammation, infection, or perforation) is typically suspected when a patient presents with lower abdominal pain (particularly on the left side). Patients may additionally present with abdominal tenderness to palpation and an elevated white blood cell count (leukocytosis). An abdominal CT will help differentiate between complicated versus uncomplicated disease in this case.

Generalized Pyoderma Gangrenosum Associated with Ulcerative Colitis: Successful Treatment with Infliximab and Azathioprine.

Pyoderma gangrenosum (PG) is a rare ulcerative skin disease, part of the spectrum of neutrophilic and auto-inflammatory dermatoses. Its pathogenesis is unknown, although immune pathways have been implicated. Lesion biopsies show a predominantly neutrophilic infiltrate. The incidence of PG is uncertain, but it is estimated to be 3-10 per million per year, occurring at any age but most commonly between 20 and 50 years with a possible slightly higher incidence in women. Approximately 50% of patients with PG also have another disease associated with PG. The most common is inflammatory bowel disease (IBD), particularly Crohn's and ulcerative colitis (UC). Local treatment may be sufficient for mild cases, while for severe cases systemic immunosuppressants are the mainstay (1,2). We report the case of a patient with bullous PG and UC successfully treated with infliximab and azathioprine. A 32-year-old male Caucasian patient presented with painful violaceous vesicles and enlarging bullae of various sizes and with acute onset, located on the trunk and bilaterally on both the lower and the upper extremities. Lesions on the trunk were composed of hemorrhagic pustules with a surrounding erythematous overhanging border. Some of the lesions had undergone central necrosis and ulceration (Figure 1, a-d). The patient reported of the lesions had appeared one week ago, simultaneously with the exacerbation of a known inflammatory bowel disease with hemorrhagic mucoid diarrhea and fever of up to 38.5°C. The patient's medical history included UC affecting the whole colon (pancolitis), diagnosed 5 months prior to the onset of the epidermal lesions, for which the patient was receiving treatment with oral prednisolone 10 mg/day and mesalazine granules. Blood tests showed severe anemia, leukocytosis, and increased inflammatory markers (C-reactive protein, erythrocyte sedimentation rate). Antinuclear antibodies (ANA), anti-double stranded DNA (anti-dsDNA) andtibodies, antineutrophil cytoplasmic antibodies (cANCA), perinuclear neutrophil antibodies (p-ANCA), antiphospholipid antibodies, and tumor markers were within normal limits. The patient was negative for cryoglobulins, viral hepatitis (B, C) and human immunodeficiency virus (HIV). Blood cultures were negative. Microscopy and cultures for mycobacteria and fungi gave negative results. Stool samples tested negative for infections agents. The Mantoux skin test was negative. Colonoscopy showed severe pancolitis, and biopsies from the rectum and sigmoid colon were consistent with chronic ulcerative colitis. Abdominal ultrasound and chest and abdominal X-rays did not result in significant findings. Because of severe anemia, the patient received 2 blood transfusions. The histopathologic examination carried out on the erythematous border of a lesion on the lower leg showed a neutrophilic infiltrate, confined to the dermis. On the basis of clinical findings, the diagnosis of PG was established. Topical wound care consisted of local wound care and a topical corticosteroid. Systemic therapy was initiated with 40 mg/day methylprednisolone for 7 days, 30 mg/day for 7 days, then 25 mg/day, and then tapered down further. The patient received an infusion of infliximab 7.5 mg/kg at weeks 0, 2, and 6 and every 8 weeks thereafter. After week 2, oral azathioprine 2.5 mg/kg daily was added to the treatment. The patient also received mesalazine tablets (2 g ×2/day) and mesalazine enema (1-2/day). The patient showed good response to treatment, with clinical remission of skin lesions. Lesions healed with characteristic thin, atrophic scars (Figure 2, a-d). At 7-month follow-up the patient was continuing with infusions of infliximab 7.5 mg/kg and azathioprine 2.5 mg/kg and was still in remission. We reported our experience with a case of generalized bullous pyoderma gangrenosum associated with ulcerative colitis. Generalized pyoderma gangrenosum is very rare. Bullous or atypical PG was first described by Perry and Winklemann in 1972 (1). Brunsting et al. coined the term pyoderma gangrenosum (PG) to describe a series of patients with recurrent ulcerations (3). The incidence of this disease is uncertain. Its pathogenesis is unknown, but an immunological background has been suggested. In approximately 50% of patients, an underlying immunological disease is present, commonly inflammatory bowel disease (IBD) (4-6). In larger series of patients with PG, approximately 50% present with a primary disorder. Ulcerative colitis is found in 10-15% of cases. Crohn's disease is associated with PG closed than UC. Less than 3% of patients with Crohn's disease or UC develop PG (6). PG is characterized by cutaneous ulcerations with mucopurulent or hemorrhagic exudate. It begins as an inflammatory pustule with a surrounding halo that enlarges and begins to ulcerate. These very painful ulcers present with undermined bluish borders with surrounding erythema. The lesions of PG most commonly occur on the legs, but they may occur anywhere on the body. The clinical picture of PG is very characteristic. Therefore the diagnosis of PG is based firstly on clinical signs and on the patient's history of underlying diseases and then supported by biopsy. PG has four distinctive clinical and histological variants. Some have morphological and histological features that overlap with other reactive neutrophilic skin conditions. There are no diagnostic serologic features (6,7). There is no evidence that the efficacy of treatment strategies for PG differs between IBD and non-IBD patients. For patients with a diffuse disease or rapidly progressive process, systemic treatment is essential. Immunosuppression is the mainstay of treatment. Traditionally, the most commonly used drugs with the best clinical experience are systemic corticosteroids. Corticosteroids have been considered as first line treatment (6,8). As reported by the European Crohn's and Colitis Organisation (ECCO) in 2008, an evidence-based consensus on the management of special situations in patients with ulcerative colitis, systemic corticosteroids are recommended (9). Treatment with corticosteroids (e.g. prednisolone 1-2 mg per kg/day or pulse therapy with 1 g of methylprednisolone) aims to prevent progression and rapidly stop inflammation (6). Additional mesalamine and corticosteroids may be effective in patients with bowel disease (10). In recent years, tumor necrosis alpha (TNF-α) inhibitors, such as infliximab and adalimumab, were reported to be effective for PG associated with IBD. These drugs block the biological activity of TNF-α, which effects regulatory T cells, restoring their capacity to inhibit cytokine production. The TNF-α inhibitors thus suppress the inflammatory processes that is involved in the pathogenesis of PG (11). Infliximab, a chimeric monoclonal antibody, is given by infusion at weeks 0, 2, and 6 and then every 8 weeks, usually at a dosage of 5 mg/kg. UC of patients with frequent disease relapse or those that are resistant or dependent on corticosteroids is often treated with purine antimetabolites, such as azathioprine (AZA) (10). AZA, a purine antimetabolite (2.5 mg per kg/day) is administered for its steroid-sparing effects. The response occurs after 2 to 4 weeks (6, 10). Infliximab can be combined with AZA. Patients with UC treated with infliximab plus AZA were more likely to achieve corticosteroid-free remission at 16 weeks than those receiving either monotherapy (10,12).