DU Health & Medical Inflammatory Bowel Disease & Urinary Obstruction Case Studies

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Case Study Inflammatory_Bowel_Disease & Urinary_Obstruction.

Case Study :

Inflammatory Bowel Disease 

The  patient is an 11-year-old girl who has been complaining of intermittent  right lower quadrant pain and diarrhea for the past year. She is small  for her age. Her physical examination indicates some mild right lower  quadrant tenderness and fullness.

Studies Results Hemoglobin  (Hgb), 8.6 g/dL (normal: >12 g/dL) Hematocrit (Hct), 28% (normal:  31%-43%) Vitamin B12 level, 68 pg/mL (normal: 100-700 pg/mL) Meckel  scan, No evidence of Meckel diverticulum D-Xylose absorption, 60 min: 8  mg/dL (normal: >15-20 mg/dL) 

120 min: 6 mg/dL (normal: >20 mg/dL) 

Lactose  tolerance, No change in glucose level (normal: >20 mg/dL rise in  glucose) Small bowel series, Constriction of multiple segments of the  small intestine 

Diagnostic Analysis 

The child’s small  bowel series is compatible with Crohn disease of the small intestine.  Intestinal absorption is diminished, as indicated by the abnormal  D-xylose and lactose tolerance tests. Absorption is so bad that she  cannot absorb vitamin B12. As a result, she has vitamin B12 deficiency  anemia. She was placed on an aggressive immunosuppressive regimen, and  her condition improved significantly. Unfortunately, 2 years later she  experienced unremitting obstructive symptoms and required surgery. One  year after surgery, her gastrointestinal function was normal, and her  anemia had resolved. Her growth status matched her age group. Her  absorption tests were normal, as were her B12 levels. Her  immunosuppressive drugs were discontinued, and she is doing well. 

Critical Thinking Questions 

1. Why was this patient placed on immunosuppressive therapy?

2. Why was the Meckel scan ordered for this patient? 

3. What are the clinical differences and treatment options for Ulcerative Colitis and Crohn’s Disease? (always on boards) 

4. What is prognosis for patients with IBD and what are the follow up recommendations for managing disease?

Case Studies

Urinary Obstruction 

The  57-year-old patient noted urinary hesitancy and a decrease in the force  of his urinary stream for several months. Both had progressively become  worse. His physical examination was essentially negative except for an  enlarged prostate, which was bulky and soft. 

Studies Results  Routine laboratory studies Within normal limits (WNL) Intravenous  pyelogram (IVP) Mild indentation of the interior aspect of the bladder,  indicating an enlarged prostate Uroflowmetry with total voided flow of  225 mL 8 mL/sec (normal: >12 mL/sec) Cystometry Resting bladder  pressure: 35 cm H2O (normal: <40 cm H2O) Peak bladder pressure: 50 cm  H2O (normal: 40-90 cm H2O) Electromyography of the pelvic sphincter  muscle Normal resting bladder with a positive tonus limb Cystoscopy  Benign prostatic hypertrophy (BPH) Prostatic acid phosphatase (PAP) 0.5  units/L (normal: 0.11-0.60 units/L) Prostate specific antigen (PSA) 1.0  ng/mL (normal: <4 ng/mL) Prostate ultrasound Diffusely enlarged  prostate; no localized tumor 

Diagnostic Analysis 

Because  of the patient’s symptoms, bladder outlet obstruction was highly  suspected. Physical examination indicated an enlarged prostate. IVP  studies corroborated that finding. The reduced urine flow rate indicated  an obstruction distal to the urinary bladder. Because the patient was  found to have a normal total voided volume, one could not say that the  reduced flow rate was the result of an inadequately distended bladder.  Rather, the bladder was appropriately distended, yet the flow rate was  decreased. This indicated outlet obstruction. The cystogram indicated  that the bladder was capable of mounting an effective pressure and was  not an atonic bladder compatible with neurologic disease. The tonus limb  again indicated the bladder was able to contract. The peak bladder  pressure of 50 cm H2O was normal, again indicating appropriate muscular  function of the bladder. Based on these studies, the patient was  diagnosed with a urinary outlet obstruction. The PAP and PSA indicated  benign prostatic hypertrophy (BPH). The ultrasound supported that  diagnosis. Cystoscopy documented that finding, and the patient was  appropriately treated by transurethral resection of the prostate (TURP).  This patient did well postoperatively and had no major problems. 

Critical Thinking Questions 

1. Does BPH predispose this patient to cancer?

2. Why are patients with BPH at increased risk for urinary tract infections?

3. What would you expect the patient’s PSA level to be after surgery? 

4.  What is the recommended screening guidelines and treatment for BPH? 5.  What are some alternative treatments / natural homeopathic options for  treatment?

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