CCS Interactive Case 3

Question 1

28 y/o M
1 week BRBPR, colicky abdominal pain
Denies sick contacts, recent travel, systemic symptoms
Hemodynamically stable
Older brother with ulcerative colitis

DDx?

Answer 1

UC, Crohn disease, diverticulosis, angiodysplasia, hemorrhoids, anal fissure, infectious colitis, ischemic colitis, colonic polyps/cancer, brisk upper GI bleed

[Diverticulosis, colon cancer/polyps more common in older patients]

Question 2

First step based on available info?

Answer 2

General, Skin, HEENT/Neck, Chest/lung, CV, Abdominal, Rectal, Extremities/Spine

{If hemodynamically unstable, first step would be resuscitation}

Question 3

Exam unremarkable except for bloodstained stool on rectal exam

Next step?

Answer 3

Flexible sigmoidoscopy or colonoscopy + rectal biopsy given high suspicion for UC

Other orders to r/o other diagnoses: CBC, BMP, ESR, stool O&P, white cells, culture, LFTs, PT/INR, PTT

Question 4

Sigmoidoscopy and rectal biopsy results are consistent with UC

Next step?

Answer 4

1. Topical 5-ASA (mesalamine suppository)
2. Antidiarrheals
3. Antispasmodics
4. Dietary consult

Do not delay treatment with 5-ASA.
Do not use systemic steroids before trying 5-ASA or steroid enema in mild case

Question 5

Range of treatment options

Answer 5

Treatment

Mild proctitis: topical therapy with 5-ASA compounds (mesalamine suppository), taper over 4-6 weeks

Moderate proctitis: oral therapy with 5-ASA compounds (sulfasalazine, mesalamine, olsalazine) + folic acid supplementation if sulfasalazine; add steroids if these fail to induce remission. NO maintenance steroids. Immunomodulators (azathioprine, 6-MP) if refractory

Severe proctitis - hospitalize, resuscitate with IV fluids/lytes, NPO, TPN, abdominal exam, vitals, abdominal x-ray to monitor for complications, IV steroids, give broad spectrum ABX if fever, leukocytosis, or sepsi, surgery if refractory

Symptom management:
Antidiarrheal agents (loperamide - avoid in severe proctitis)
Anticholinergics for abdominal cramps
Antidepressants/anxiolytis for associated mood disorders

Dietary counseling
Anual surveillance colonoscopy beginning 8-10 years after diagnosis

Question 6

Monitoring?

Answer 6

ESR

Question 7

Location?

Answer 7

Office, then Home

[ER, Ward acceptable]

ICU not acceptable

Question 8

Sequence:

Answer 8

-Exam
-Orders
-Location: send the patient home
-Clock: schedule an appointment in a week, advance to obtain results, note elevated ESR
-Order: sigmoidoscopy, rectal biopsy
-Clock: advance too obtain results, Dx UC
Location: bring patient back to office
Order: mesalamine, loperamide, dicyclomine, dietary consult, counseling
Location: send patient home
Clock: schedule appointment in 2 weeks, case ends
Final orders: none
Primary diagnosis: UC, mild case involving rectum and sigmoid coon