phuluong2k
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A 65 year old man has a 4 month history of severe steady pain in the left mid-abdomen that develops approximately 30 minutes after eating
He has lost 20 pounds for fear of eating, he now presents with similar pain, bloody diarrhea, abdominal distention, and hypotension. his serum amylase is markedly elevated, and there is an absolute neutrophilic leukocytosis with a shift to the left.
The pathogenesis of this condition most closely relates to
A. Neoplastic process
B. ischemic injury to bowel
C. Infectious process
D. Mechanical obstruction
E. Inflammatory bowel disease
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| mjl1717
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neoplasm?
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| Dan Ivanov
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I'd say C, there's a penetrating ulcer into pancreas parenchima.
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| lmbebo
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my best guess is B,
just not sure with the 4 mo h/x and left shift. Could be an infectious process going on as well.
not neoplasm b/c right side bleeds, left side obstructs. plus I think most cancers, while they do bleed, won't cause bloody diarrhea unless its really progressed, etc.
At his age it could be diverticulitis., but its not really consistent with the history time wise.
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| aali
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penetrating post wall duodenal ulcer into pancrease I will go for C
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| Kazem
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I agree with aali and dan ivanov, as this sounds like a perforated duodenal ulcer that has penetrated the posterior structures such as the pancreas. H.Pylori can cause this situation and a a result PMN levels can rise. although the age and the weight loss suggest neoplasm, neutrophilic leukocytosis and the reason behind the weight loss, rules out the neoplasm to some extent and suggest an infectious process. this is how I see it. please correct me if I'm wrong. thanx.
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| phuluong2k
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This q on goljan pathology reiview page 205
Answer ischemic injury to bowel
The patient most likely had mesenteric angina owing to atherosclerosis of superior mesenteric artery to explain his history after eating. He now has an infart in his small bowel ( bloody diarrhea, increase amylase of bowel origin ) mostl likely due to thrombus over the same artery
Chronicity of disease so argues against infection
Mechanical obstruction produce absence of stool and gas , colicky pain
Neoplasm produces alternating bouts of constipation and non bloody diarrhea
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| Kazem
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That was a good question and a tricky one :wink:
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