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.
Vitamin B12 level,
8.6 g/dL (normal: >12 g/dL)
28% (normal: 31%-43%)
68 pg/mL (normal: 100-700 pg/mL)
No evidence of Meckel diverticulum
60 min: 8 mg/dL (normal: >15-20 mg/dL)
120 min: 6 mg/dL (normal: >20 mg/dL)
Small bowel series,
No change in glucose level (normal: >20 mg/dL rise in
Constriction of multiple segments of the small intestine
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
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.
Routine laboratory studies
Intravenous pyelogram (IVP)
Uroflowmetry with total voided
flow of 225 mL
Electromyography of the pelvic
Prostatic acid phosphatase
Prostate specific antigen (PSA)
Within normal limits (WNL)
Mild indentation of the interior aspect of the bladder,
indicating an enlarged prostate
8 mL/sec (normal: >12 mL/sec)
Resting bladder pressure: 35 cm H2O (normal: <40 cm H2O)
Peak bladder pressure: 50 cm H2O (normal: 40-90 cm H2O)
Normal resting bladder with a positive tonus limb
Benign prostatic hypertrophy (BPH)
0.5 units/L (normal: 0.11-0.60 units/L)
1.0 ng/mL (normal: <4 ng/mL)
Diffusely enlarged prostate; no localized tumor
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
Does BPH predispose this patient to cancer?
Why are patients with BPH at increased risk for urinary tract infections?
What would you expect the patient’s PSA level to be after surgery?
What is the recommended screening guidelines and treatment for BPH?
What are some alternative treatments / natural homeopathic options for treatment?
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