Which test, coronary angiography or colonoscopy?

Abstract

A 87-year-old man was conducted to the Emergency Unit after a syncope. At admittance, the patient was awake, asymptomatic for chest pain, Troponin I values were 0.02 lg/L, Glasgow coma scale (GCS) score was 15, the blood pressure 110/ 55 mmHg, the pulse 90 beats per minute, the peripheral oxygen saturation 98%. Laboratory tests only showed microcytic hypochromic anemia [hemoglobin level 9.8 g/dL; hematocrit 31.1%; mean cell volume (MCV) 77.7 fL; mean cell hemoglobin (MCH) 24.3 pg; mean concentration of hemoglobin per volume of red cells (MCHC) 31.3 g/dL]. He reported assumption of sublingual nitrates some minutes before the syncope for chest pain caused by a mild effort (Valsalva). Six hours after admittance, the patient was still asymptomatic, his conditions appeared stable, Troponin I values remained within the normal range and he was transferred to our medical ward to complete the diagnostic and therapeutic work-up. Relevant past history included, 11 years before, demonstration of coronary artery disease (CAD) [75% stenosis of left circumflex and first obtuse marginal arteries, 50% stenosis of mid left anterior descending artery, and subcritical stenosis (\50%) of second obtuse marginal artery], treated with medical therapy. Few months after diagnosis of CAD, acetylsalicylic acid (ASA) was substituted by ticlopidine because of melena and heartburn; at that time an esophagogastroduodenoscopy (EGDS) showed no lesions. Thereafter the patient suffered from chronic angina with stable threshold (functional classification class II of the Canadian Cardiovascular Society) relieved by nitrates. Five years before the admission a microcytic hypochromic anemia was demonstrated, an EGDS was repeated and showed chronic atrophic gastritis with Helicobacter-like organism (HLO) ?, eradication therapy was started but discontinued for adverse effects. A contemporary gradual reduction of the anginal threshold was noted. Six months before the admission anorexia, with weight loss of about 7 kg, and constipation developed. Physical examination revealed: pale discoloration of skin, high-frequency low-grade systolic murmur audible on all cardiac auscultation areas, a non-tender non-pulsatile roundish mass deeply palpable in the right iliac fossa of several (6–8) centimetres of diameter, of increased consistency and preserved mobility on abdominal wall. Ultrasound examination of the abdomen was performed and revealed a kidney-shaped mass of 7 9 7 9 8 cm dimensions, suggesting a right colon cancer. Colonoscopy showed an ulcerated cauliflower-shaped lesion in the cecum occupying the whole intestinal lumen. The histological examination of a biopsy specimen confirmed the diagnosis of the adenocarcinoma of the colon. CT scan of the abdomen showed a large irregular thickening of the cecum wall with regional lymph nodes involvement without signs of distant metastases. I. Cecioni F. Fassio C. Alamanni F. Almerigogna Division of Immunology and Cellular Therapies, Department of Internal Medicine, University of Florence, Florence, Italy