Fizz Eoh is a 23 year old woman who has presented to the Emergency Department with severe joint pain. It began in her wrist and has moved to her elbows. She was tolerating this for some time, however she feels generally more unwell today. She has had 'intense' diarrhoea for a week, which is what led her to present to A&E, since she passed out on the toilet earlier today. She is most concerned about the passing out, rather than the abdominal symptoms, as she has 'always had a dodgy tummy'. She takes sertraline for depression. The diarrhoea has happened once before, around 2 months ago, and lasted for 2 weeks: she declined to go to hospital at that time. She has not vomited.
You undertake a very thorough examination. Her chest is clear, whilst abdominal exam reveals pain in right iliac fossa. Palpation leads to her shouting a few choice phrases, whilst her abdomen is tender. Bowel sounds are present and the rest of abdominal exam is normal. The wrist is clearly inflamed with a reduced range of movement, both passive and active. She is apyrexial. Full exposure (because this is a very thorough examination) reveals multiple small red lumps on her shins, which she only noticed yesterday after her regular leg wax.
Bloods show a raised WCC as well as a raised albumin. CRP and ESR are also high but LFT and U&E's have come back normal. Her Hb is 100, whilst her MCV is 71.
Over to you - what would you like?
ANTI-TTG RESULT: Negative
ANTI-CCP RESULT: Negative
Stool culture: type 7 stool, negative for all organisms
Colonoscopy results: Appearance of ulceration. On histology: mucosal and submucosal inflammation
Now select your winner!
You picked:
Correct answer:Inflammatory bowel disease
This lady presents with change in bowel habit: which could be indicative of gastroenteritis. However, there are associated symptoms which are not necessarily associated with bowels: feeling generally unwell, lesions suggestive of erythema nodosum, anaemia and raised white cells. The possible investigations here should help with diagnosis. Anti TTG is used to help diagnose coeliac and is negative. Colonoscopy shows ulceration, with inflammation - this suggests inflammatory bowel disease.
