We ruled it in because of the symptoms that are present in the patient that can be found on toxic

megacolon such as abdominal pain, bloody diarrhea of 4-5 times per day, nausea, vomiting,
hypotension, weight loss, anorexia, and malaise. However we ruled it out because the patient
has no fever, ascites, no anemia, and the patient has normal albumin.

For the inflammatory bowel disease, we ruled it in because the patient presented with diarrhea
(Blood streaked, semi formed, non foul smelling stool), anorexia, malaise, weight loss,
leukocytosis and presence of pus cells and mucus threads in urinalysis and this cannot be totally
ruled out.

For the amoebic colitis, we ruled it in due to the abdominal pain, malaise , nausea, anorexia,
weight loss, coffee ground vom, diarrhea of 4-5 times bowel movements per day (blood streaked,
semi formed, non foul smelling stool), hypo-normoactive bowel sounds, segment ileus in upper
abdomen, hepatic nodules, hepatomegaly, bibasal pneumonia, leukocytosis and the presence of
Entamoeba histolytica cyst in the fecalysis. Therefore, it cannot be totally ruled out.

So our main diagnosis is Amoebic Colitis.

The most common presenting symptoms in CD are fatigue and abdominal pain while in
UC bloody BM and diarrhea are most common. 

Almost 90% of infections are asymptomatic. Individuals who are colonized but remain
asymptomatic raise a significant risk to others because they are cyst passers and therefore,
infective. Symptomatic clinical infection may appear as an acute infection in the colon called
amebic colitis. Amebic colitis typically presents with symptoms of diarrhea with blood in the
stools, although the symptoms can be nonspecific. When compared to bacterial colitis, amebic
colitis has a more gradual onset. Amebic colitis can closely simulate ulcerative colitis or Crohn
disease on clinical grounds.[12] On physical examination, the patient may have either localized
or diffuse tenderness on palpation. Rarely, a palpable mass may be present. If undiagnosed and
untreated a patient may present with toxic megacolon which presents as an acute dilatation of the
colon. This complication carries a high mortality due to associated necrosis and perforation.
Fewer than 1% of patients with amebic colitis have associated extraintestinal infection, the
commonest being a liver abscess. Patients with liver abscesses may have symptoms such as
fever, chills, and pain in the upper right quadrant or can be asymptomatic. Weight loss, increased
white blood cell counts, or elevated liver enzyme levels may be present. Jaundice is usually
absent.[13] Lung abscesses may develop as the result of penetration of the diaphragm by amebae
from hepatic abscesses or hematogenous spread. Invasion of the lung can cause symptoms such
as chest pain, dyspnea, and a productive cough.
Toxic megacolon develops in patients of all ages and both sexes.2 The patient usually presents
with signs and symptoms of colitis before the onset of toxic megacolon.2 The symptoms of
colitis include diarrhea, fever, chills, and abdominal cramping.2 Patients developing toxic
megacolon may exhibit (1) constipation, (2) malaise, (3) a white blood cell count greater than
10,500/2L, (4) anemia less than 12 g, (5) albumin less than 3 g, (6) tachycardia, (7) fever, (8)
shock, and/or (9) hypotension.1 Physical examination may reveal a locally or diffusely tender
abdomen, reduced bowel sounds, abdominal distention, and an altered mental status.5 Patients
are often administered antibiotics, immunosuppressants or chemotherapy, or antidiarrheals
before developing toxic megacolon.1

The diagnosis of toxic megacolon is based on the clinical picture of severe systemic toxicity and
plain abdominal films revealing a dilated colon (see Table 2). Toxic megacolon should be
considered in all patients presenting with abdominal distention and acute or chronic diarrhea.5
The best-accepted clinical criteria for diagnosing toxic megacolon uses any 3 of the 4 following
criteria: (1) temperature greater than 101.5-F, (2) heart rate greater than 120 beats/min, (3) white
blood cell count greater than 10.5 109 /L, or (4) anemia. Patients should also have one of the
following: (1) dehydration, (2) mental changes, (3) electrolyte disturbances, or (4) hypotension.3
Abdominal radiographs should be obtained in the left lateral decubitus and supine positions.4
The radiological diagnosis is made when transverse colon or ascending colon are greater than 6
cm dilated.2 Plain films often show a loss of haustrations in patients with pseudomembranous
colitis.
1 It is recommended that abdominal CT be obtained because it is useful in determining the
etiology of toxic megacolon.2 Computed tomography has the ability to show diffuse colonic wall
thickening, submucosal edema, periodic stranding, septic emboli, and abscesses that may not
appear on a plain film.2 Laboratory studies are nonspecific yet may be helpful in the diagnosis of
toxic megacolon.2 Leukocytosis is usually noted with a left shift indicating the degree of
inflammation and the leukocyte count may reach as high as 40,000/2L.4 It is important to
remember that neutropenia, not leukocytosis, may be seen in patients with AIDS or those
receiving chemotherapy.5 Metabolic acidosis and electrolyte imbalances such as low potassium,
calcium, chloride, phosphate, and magnesium may occur from prolonged diarrhea.4
Hypoalbuminemia is usually not present initially, but the albumin level often drops below 3 g/dL
because of chronic protein losses and decreased liver synthesis with malnutrition.4 A poor
prognosis results when a patient develops metabolic alkalosis from volume depletion and
potassium losses.4 Elevated erythrocyte sedimentation rate and C-reactive protein levels are
nonspecific inflammatory signs often useful when observing the progression of the disease.

Stool samples should be sent for culture, sensitivity, and C difficile toxin assay in patients with a
history of antibiotic use or chemotherapy to help determine a diagnosis for pseudomembranous
colitis.4 It is important to consider an ova and parasite infection and cytomegalovirus in patients
with HIV/AIDS.4 Blood cultures should obtained to rule out bacteremia, considering that sepsis
occurs in up to 25% of patients with toxic megacolon.2 A limited endoscopy, not full
colonoscopy, without bowel preparation may be useful to diagnose a suspected infection in the
colon. Only minimal amounts of air should be used because of the risk of worsening distention,
ileus, or perforation.2