Laboratory evaluation returns with the following significant labs:
- CBC: Hgb 11 with MCV 80, Plt 500
- ESR 28, CRP 15 (both high)
- AST 50, ALT 40 (both high) Alkaline phosphatase normal
- C. diff negative, Stool bacterial cultures negative, Giardia antigen negative
- Fecal Calprotectin 732 (high)
What will be your next step
Reassurance
In this patient with evidence of chronic bloody diarrhea and elevated inflammatory markers, simple reassurance is inappropriate as further workup to determine the cause of the clinical presentation is necessary
Perform anoscopy to look for hemorrhoids
While this patient has had chronic hematochezia which can be explained by hemorrhoids, her urgency, tenesmus, diarrhea and elevated inflammatory markers are inconsistent with a diagnosis of hemorrhoids
MR Enterography
MRE can be useful in evaluating for small bowel pathology. However in this patient with a clinical history consistent with colonic involvement (bloody diarrhea, urgency, tenesmus and elevated fecal calprotectin), direct investigation of the colon is necessary.
Colonoscopy
This patients bloody diarrhea, urgency, tenesmus, and elevated serum and stool inflammatory markers should be evaluated with colonoscopy and biopsy to determine the source of inflammation.
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