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Dr. Andrew Rynne

Family Physician

Exp 50 years

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What do these lab reports indicate?

Answered by
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Dr. Ramesh Kumar

Gastroenterologist

Practicing since :1986

Answered : 1956 Questions

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Posted on Tue, 12 Jun 2018 in Digestion and Bowels
Question: Hi,
My mother was diagnosed with gall bladder cancer in Nov 2014. She is under treatment since then. She was doing fine until Nov 23, 2017. On Nov 23 , she passed stool with blood. She was admitted to hospital but the cause of bleeding was not determined. She was discharged and within a week it happened again. She was admitted to hospital and all possible tests were done but the cause of bleeding was not found.Doctors are surprised as they are not able to find out what exactly is happening. Meanwhile in 10 days bleeding decreased and she was normal again. Today, on XXXXXXX 5th she again passed blood with stool. We are on our way to hospital but need some expert advice on this. My mother is in XXXXXXX currently.

Following is the summary from hospital reports.
46 yr female patient / Hypothyroidism
Case of Ca GB s/p radical cholecystectomy with EHBTE in Nov 2014
s/p Adj chemotherapy GEMCIS 6 #
Developed Recurrence with OJ with cholangitis with type Iv block in sept 2015
Underwent B/L 10 x 100 SEMS done--3/10/2015
Styarted on CPIRI
Intrim IVC bland thrombosis started on anticoagulation
H/o multiple episodes of cholangitis in intrim
Underwent left PTBD for cholangitis and left stent block in Feb 2016
received RT (55GY/25# from 26.216 to 6.4.16)
Continued to have repeated episodes of cholangitis treated withantibiotics
Bili--2.32 7/3/2016
subsequent imaging s/o mild IHBRD with min pneumobilia and progressively increasing splenomeglay
Now, hematochezia and malena in last week of november
UGI scopy outside--normal
colonoscopy --altered blood in one scopy and then normal scopy after repeat preparation.
Patient presented now with bleeding PR marron colour large qty with clots since last 2 days 3-4 episodes
No hematmesis
h/o blood transfusion 1 PC
ct angio s/o no obvious arterial blush in visualised part (lower abdomen angio could not be performed due to tech error)
CECT 29.11.2017 - No significant change in the ill defined soft tissue lesion along the SMA.
-No significant change in the abdominal nodes.
Diffuse mesentric fat stranding with mild ascites and right sided mild pleural effusion are the new findings.
Diffuse subcutaneous edema is also seen.
doctor
Answered by Dr. Ramesh Kumar 21 hours later
Brief Answer:
A difficult case, please provide some further details.

Detailed Answer:
Hello,
Thank you for asking at HealthcareMagic.

I read your question carefully and understand your concern.

As colonoscopy and endoscopy along with other tests are normal.The only possibility left is irritable bowel syndrome.

Irritable bowel syndrome sometimes causes blood on stools.They may be occasional or maybe there with every stool.

Are the stools black or bloody?

What are your bowel movements like?" or "Have you experienced a change in your bowel movement?

Have you vomited during the past year?" If the answer is yes, ask, "What did it look like?" "Was it bloody?"

"Was it brown, or did it look like coffee grounds?"

Have you observed blood in or on your stools or on the toilet paper?

Do you sometimes bleed from the rectum without passing stool?"

Please clarify these so that I can guide you further...

Awaiting!


Above answer was peer-reviewed by : Dr. Arnab Banerjee
doctor
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Follow up: Dr. Ramesh Kumar 8 hours later
Thank you doctor for your response. Below are the responses for your questions:
Let me know if you would like to go through additional test results or reports:
Are the stools black or bloody?
When it first started on Nov 22, 2017, the stools were black and we did not realise it was blood. After two days she was passing only blood along with blood clots. We admitted her to hospital when we realised it was blood. After 7 days in hospital, she got back to normal and was discharged on 3rd Dec. However on 16th Dec 2017, she started passing blood again. It wass only blood with some clots. We immediately took her to hospital. In hospital they did several tests to figure out the source of bleeding but were unable to find out. However, after 4-5 days bleeding slowely decreased and eventually stopped. She was discharged on 30th Dec. YEsterday, on 5th of Dec same thing happened again.She is in hospital at the moment. D

What are your bowel movements like?" or "Have you experienced a change in your bowel movement?
HEr bowel movements are not consistent these days. Before bleeding started, she complained of either loose motion or constipation. After bleeding started sometimes she has normal bowel movements while somedays she has loose motion.

Have you vomited during the past year?" If the answer is yes, ask, "What did it look like?" "Was it bloody?"
YEah, after chemotherapy she feels nauseaus on several days and also vomits. However, vomits are not bloody.

"Was it brown, or did it look like coffee grounds?"
Vomit was not bloody or brown. It is normal yellowish in color. Sometimes , she throws up whatever she eats.

Have you observed blood in or on your stools or on the toilet paper?
When she is bleeding, her stool does not contain anything else. Its mostly blood. Sometimes , its fresh blood while sometimes it is clotted.

Do you sometimes bleed from the rectum without passing stool?"
No, it has not happened. She does not passes blood from rectum.


She experienced fresh bleeding yesterday and is admitted to hospital .Doctors are continuing supportive care. They told us they have done all the tests to find out the bleeding source but they are not able to find it.They assume bleeding is from somewhere in small intestine. They also said, they can treat it if they are able to figure out the source of bleeding. Is there any other way that the source of bleeding can be found.

I've also attached reports and clinical notes from yesterday, since she was admitted to the hospital.
doctor
Answered by Dr. Ramesh Kumar 12 hours later
Brief Answer:
follow up.

Detailed Answer:
Report says that your dad has radiation enteritis.This condition is caused by the inflammation of your small and/or large intestine.Radiation enteritis can cause the loss of both intestinal cells and tissue.Enteritis means inflammation of particular part of intestine.These points of inflammation along the intestines can act as source of bleed.Reports also suggest that he has radiation enteritis
However if bleed is massive only way is to go for open lapractomy(abdomen is cut open to find out source of bleed).
What do doctors at your hospital suggesting?
Have they told you about lapractomy?

.
Above answer was peer-reviewed by : Dr. Prasad
doctor
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Follow up: Dr. Ramesh Kumar 3 hours later
The initial report suggested radiation enteritis. Please see the comments from doctors below:
"Few scattered telangiectasias are seen in D1. Rest of the duodenum was normal. Mucosal oozing was noted in proximal jejunum.
s/o radiation enteritis "

But the radiation expert denied radiation enteritis. Below are the comments from radiation departement:

"     S/B Dr XXXX

Case of Ca GB Post op post CT 2014, Recurence in 2015
post RT 2016
now p/w UGI bleeding

UGI scopy- s/o telengectasia in D1, rest of the duodenum normal, mucosal ooze from proximal jejunum

RT plan reviewed -
Jejunum far from planning target volume
Mean duodenal dose-5.6Gy (in 25 fractions) and Jejunum received less than 2Gy in 25 fractions

D/W Dr XXXXXXX Engineer
Highly unlikely to be RT enteritis

To consider for surgical exploration for further evaluation and management"


Doctor did tell us about the lapractomy but my mother has become very weak due to all the ongoing procedures and she does not want to undergo any invasive procedure.
How complicated is this procedure and how much time does it take for a patient to recover.?
Is there any other way/tests which arre not invasive and can help figure out the source of bleeding?
doctor
Answered by Dr. Ramesh Kumar 13 hours later
Brief Answer:
Follow up answer.

Detailed Answer:
Hello again XXXX,
Lapractomy as such is not a complicated procedure and is among one of the most basic surgeries performed. However as your mother is too week at present to sustain any surgeries wait and watch is only possible way.

Already all tests have been done so right now all ican suggest is wait and watch.

Above answer was peer-reviewed by : Dr. Kampana
doctor
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The User accepted the expert's answer

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