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Inflammatory Bowel Disease and Urinary Obstruction

Inflammatory Bowel Disease and Urinary Obstruction

Case Study
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.
Studies Results
Hemoglobin (Hgb), 8.6 g/dL (normal: >12 g/dL)
Hematocrit (Hct), 28% (normal: 31%-43%)
Vitamin B12 level, 68 pg/mL (normal: 100-700 pg/mL)
Meckel scan, No evidence of Meckel diverticulum
D-Xylose absorption, 60 min: 8 mg/dL (normal: >15-20 mg/dL)
120 min: 6 mg/dL (normal: >20 mg/dL)
Lactose tolerance, No change in glucose level (normal: >20 mg/dL rise in
glucose)
Small bowel series, Constriction of multiple segments of the small intestine
Diagnostic Analysis
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 the prognosis for patients with IBD and what are the follow-up recommendations for managing disease?

Urinary Obstruction
Case Studies
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.
Studies Results
Routine laboratory studies Within normal limits (WNL)
Intravenous pyelogram (IVP) Mild indentation of the interior aspect of the bladder,
indicating an enlarged prostate
Uroflowmetry with total voided
flow of 225 mL
8 mL/sec (normal: >12 mL/sec)
Cystometry Resting bladder pressure: 35 cm H2O (normal: <40 cm H2O)
Peak bladder pressure: 50 cm H2O (normal: 40-90 cm H2O)
Electromyography of the pelvic
sphincter muscle
Normal resting bladder with a positive tonus limb
Cystoscopy Benign prostatic hypertrophy (BPH)
Prostatic acid phosphatase
(PAP)
0.5 units/L (normal: 0.11-0.60 units/L)
Prostate specific antigen (PSA) 1.0 ng/mL (normal: <4 ng/mL)
Prostate ultrasound Diffusely enlarged prostate; no localized tumor
Diagnostic Analysis
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
1. Does BPH predispose this patient to cancer?
2. Why are patients with BPH at increased risk for urinary tract infections?
3. What would you expect the patient’s PSA level to be after surgery?
4. What is the recommended screening guidelines and treatment for BPH?
5. What are some alternative treatments / natural homeopathic options for treatment?

 

 

Inflammatory Bowel Disease and Urinary Obstruction

Inflammatory Bowel Disease

Why the Patient was Placed on Immunosuppressive Therapy

The patient was placed on immunosuppressive therapy in order to prevent the immune system from causing inflammation because immunosuppressive therapy reduces the activity of the immune system (Boyapati et al., 2018). Crohn’s disease may be treated with drugs that stop the immune system from causing inflammation. This is because Crohn’s disease is an inflammatory chronic disease of the GIT and it is an autoimmune disease that causes the immune system to mistakenly attack healthy body tissues (Boyapati et al., 2018). Therefore, immunosuppressive therapy will decrease the activity of the immune system in attacking healthy body tissues.

Why Meckel Scan was Ordered for this Patient

Meckel’s scan was ordered because Meckel’s diverticulum is associated with ileitis and thus can be confused with Crohn’s disease due to similar presenting symptoms. Meckel’s diverticulum presents with symptoms such as small bowel ulcerations, pain, diarrhea, bright red blood per rectum, and obscure gastrointestinal bleeding, just like in Crohn’s disease (Kassim et al., 2018). However, it does not have the histological evidence of Crohn’s disease. Meckel’s diverticulum is caused by the incomplete destruction of the vitelline duct, leading to the formation of diverticulum of the small intestine (Kassim et al., 2018). Therefore, a Meckel scan would be necessary to rule out Meckel’s diverticulum.

Clinical Differences and Treatment Options for Ulcerative Colitis and Crohn’s Disease

Crohn’s disease affects the whole of the digestive tract, while ulcerative colitis only affects the large intestine. In addition, in Crohn’s disease, there are healthy regions between the areas with inflammation, while in ulcerative colitis, there are no healthy areas between the areas with inflammation (Lee et al., 2018). Finally, since Crohn’s disease has more effect on the whole of the digestive tract, patients experience some clinical problems not present in ulcerative colitis such as mouth sores, infections, anal tears, or narrowing. Moreover, megacolon is a common symptom in ulcerative colitis, while abscesses are common in Crohn’s disease (Lamb et al., 2019).

For the treatment options, the two conditions can be managed through suitable use of drugs that target the inflammatory responses of the body. Decreasing inflammation can lower and get rid of symptoms such as diarrhea and pain (Lee et al., 2018). Due to the similarities between the two diseases, their treatment options are similar. However, in ulcerative colitis complete remission is possible, unlike Crohn’s disease where complete remission of symptoms is less common. Additionally, surgery is a common treatment option in Crohn’s disease, unlike in ulcerative colitis.

Prognosis and Follow-Up Recommendations for Patients with IBD

The chance of survival in people with IBD is good and the mortality rate in IBD is low. It is important to adhere to the prescribed treatment regimens in IBD. Patients are advised to eat a variety of foods as tolerated (Cury et al., 2019). Dietary recommendations include limiting the intake of dairy products, taking low-fat foods, avoiding high-fiber foods, and avoiding spicy foods, smoking, and alcohol intake (Cury et al., 2019).

 

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Urinary Obstruction

BPH and Cancer Predisposition

BPH predisposes the patient to different types of cancers. According to Dai et al (2016), BPH is linked to an increased incidence of bladder cancer and prostate cancer. However, some studies indicate that BPH is not associated with cancer and does not increase an individual’s risk of having prostate cancer

Why Patients with BPH at Increased Risk for Urinary Tract Infections

People with BPH are at an elevated risk of urinary tract infections because individuals are not able to empty the bladder completely. The remaining urine in the bladder acts as the growth medium for microorganisms such as bacteria (Lee & Kuo, 2017). Therefore, patients with BPH should be closely monitored for urinary tract infections.

Patient’s PSA Level to be after Surgery

The prostate-specific antigen (PSA) levels are expected to reduce to undetectable levels after the surgery (Gunda et al., 2018). This is especially with the removal of the entire prostate, where the PSA levels reduce almost to zero.

Recommended Screening Guidelines and Treatment for BPH

Men presenting with symptoms of lower urinary tract infections need a history assessment to determine the severity of symptoms and examine other causes of the symptoms. Men who are suspected to have BPH should be assessed using a validated questionnaire in order to quantify the severity of the symptoms (Davidian, 2016). In men presenting with symptoms of BPH, a urinalysis and a digital rectal examination are recommended to screen for other urologic infections. For men with mild BPH, they should be monitored carefully. Patients with severe and moderate symptoms of BPH should be administered with alpha-blockers to have symptomatic relief. In men having prostate volume higher than 40 mL, the patients should be administered with 5-alpha reductase inhibitors. If the treatment fails and the patient develops persistent hematuria, refractory urinary retention, and bladder stones, the patient should be referred for surgical consultation (Davidian, 2016).

Alternative Treatments/Natural Homeopathic Treatment Options

Some primary alternative remedies in the treatment of BPH include chimaphilla umbellata and pulsatilla. Chimaphilla umbellata helps in relieving urine retention and frequent urge to urinate. Pulsatilla is used to relieve discomfort associated with prostate problems (Kim et al., 2019). Saw palmetto is also a herbal remedy obtained from a palm tree and it is used to relieve urinary symptoms, encompassing the symptoms caused by an enlarged prostate. Homeopathic treatments that have been shown to be effective in the treatment of BPH include moxibustion and acupuncture. Lifestyle modifications such as being physically active, taking a lot of water, reducing alcohol intake, and consuming a healthy diet are effective in managing BPH (Kim et al., 2019). For example, soy and astragalus are medicinal plants used to boost the immune system and reduce the effects of BPH.

 

 

References

Boyapati, R. K., Torres, J., Palmela, C., Parker, C. E., Silverberg, O. M., Upadhyaya, S. D., Nguyen, T. M., & Colombel, J. F. (2018). Withdrawal of immunosuppressant or biologic therapy for patients with quiescent Crohn’s disease. The Cochrane database of systematic reviews, 5(5), CD012540. https://doi.org/10.1002/14651858.CD012540.pub2

Cury, D. B., Oliveira, R., & Cury, M. S. (2019). Inflammatory bowel diseases: time of diagnosis, environmental factors, clinical course, and management – a follow-up study in a private inflammatory bowel disease center (2003-2017). Journal of inflammation research, 12, 127–135. https://doi.org/10.2147/JIR.S190929

Dai, X., Fang, X., Ma, Y., & Xianyu, J. (2016). Benign Prostatic Hyperplasia and the Risk of Prostate Cancer and Bladder Cancer: A Meta-Analysis of Observational Studies. Medicine, 95(18), e3493. https://doi.org/10.1097/MD.0000000000003493.

Davidian, M. H. (2016). Guidelines for the treatment of benign prostatic hyperplasia. US Pharm, 41(8), 36-40.

Gunda, D., Kido, I., Kilonzo, S., Nkandala, I., Igenge, J., & Mpondo, B. (2018). Prevalence and Associated Factors of Incidentally Diagnosed Prostatic Carcinoma among Patients Who Had Transurethral Prostatectomy in Tanzania: A Retrospective Study. Ethiopian Journal of health sciences, 28(1), 11–18. https://doi.org/10.4314/ejhs.v28i1.3

Kassim, T., Abdussalam, A., & Jenkins, E. (2018). Meckel’s Diverticulum in Crohn’s Disease Revisited: A Case of Meckel’s Diverticulitis in a Patient with Stricturing Crohn’s Disease. Cureus, 10(6), e2865. https://doi.org/10.7759/cureus.2865

Kim, J. H., Park, K. M., & Lee, J. A. (2019). Herbal medicine for benign prostatic hyperplasia: A protocol for a systematic review of controlled trials. Medicine, 98(1), e14023. https://doi.org/10.1097/MD.0000000000014023

Lamb, C. A., Kennedy, N. A., Raine, T., Hendy, P. A., Smith, P. J., Limdi, J. K., … & Barrett, K. J. (2019). British Society of Gastroenterology consensus guidelines on the management of inflammatory bowel disease in adults. Gut, 68(Suppl 3), s1-s106.

Lee, H. S., Park, S. K., & Park, D. I. (2018). Novel treatments for inflammatory bowel disease. The Korean Journal of internal medicine, 33(1), 20–27. https://doi.org/10.3904/kjim.2017.393.

Lee, C. L., & Kuo, H. C. (2017). Pathophysiology of benign prostate enlargement and lower urinary tract symptoms: Current concepts. Ci Ji Yi xue za zhi = Tzu-chi medical journal, 29(2), 79–83. https://doi.org/10.4103/tcmj.tcmj_20_17.

 

 

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