“Her intestines are acting much worse this time.” The case of Melanie K Melanie first became ill at age 21 with a chronic ailment characterized by intestinal symptoms: fever, diarrhea, abdominal pain,...

“Her intestines are acting much worse this time.” The case of Melanie K

Melanie first became ill at age 21 with a chronic ailment characterized by intestinal symptoms: fever, diarrhea, abdominal pain, and bloody stools. Lack of international travel and negative stool cultures excluded infection. Fever and bloody stools exclude the possibility of IBS because IBS is purely a functional disease without objective laboratory or physical abnormalities. Age, a relative with a chronic intestinal ailment, the presence of arthritis with flare-ups, and the chronic nature of the illness suggested IBD. X-ray studies showed disease mainly in her small bowel. A diagnosis of Crohn IBD was made but biopsy proof was lacking until her surgery five years later. At the time of her hospitalization five years later, she was anemic (low hemoglobin and hematocrit) and suffering from nutritional deficiency (low blood protein). The anemia can be explained by chronic blood loss from intestinal bleeding that depleted iron stores more rapidly than they could be replenished by diet. Also, bowel disease could have interfered with iron absorption. Low serum iron confirmed the diagnosis of iron deficiency anemia. Low blood protein could be due to inadequate diet or epithelial phase malabsorption of nutrients due to mucosal inflammation. Both are probably responsible. Low body mass index confirms the suspicion of malnutrition. Surgery produced proof of Crohn disease in the pathology specimen. The full thickness of the bowel wall was inflamed. By contrast, UC involves only the mucosa. That a fistula was present and inflammation spread to pelvic organs and peritoneum was also consistent with Crohn disease. The big surprise in this case was an adenocarcinoma of the colon (cecum). Though not unheard of in Crohn, it would not have been a surprise if she had UC. In retrospect, the degree of rectal bleeding was a clue that something else was going on. Rectal bleeding is much more common in UC, but in this case was easily explained by bleeding from the colon cancer.