it's time a 63-year-old woman was admitted because of severe abdominal pain, fatigue and bloody...
TRANSCRIPT
It's Time
• A 63-year-old woman was admitted because of severe abdominal pain, fatigue and bloody diarrhea.
• Her symptoms had started about 3 months prior to admission. She was initially evaluated by her local physician, referred to a surgeon and underwent an exploratory laparotomy.
• The surgeon described an inflamed colon and transferred her for further management to the hospital
• The terminal ileum was spared. Biopsies were most consistent with active ulcerative colitis. No viral inclusions were seen.
• She was started on prednisone and mesalamine. About 2 weeks later, she presented with worsening symptoms despite medical therapy.
• The examination revealed a Cushingoid facies, pallor and had some periorbital edema. The abdomen was diffusely tender with rebound tenderness.
• The laboratory tests demonstrated an anemia with a hemoglobin of 11.9 g/dl, leukocytosis with 12,700/ 祃 and hypalbuminemia with 1.9 g/dl. A plain film of her abdomen did not show free air.
• Because of her physical findings, a CT scan was obtained, which revealed thickening of the colonic wall .
• Stool studies were positive for Clostridium difficile toxin, and treatment with vancomycin was started. She received intravenous steroids and total parenteral nutrition for bowel rest.
• Her symptoms improved slightly. As the pattern of her colonoscopic findings with relative rectal sparing raised the possibility of Crohn disease, a small bowel follow-through was performed to see whether she might be a candidate for infliximab therapy.
Discussion:
• About 10 ?15 % of patients present with refractory inflammatory bowel disease at the onset of their illness.
• Ongoing bleeding, perforation or toxic megacolon may lead to emergency surgery. Therefore, an experienced surgeon should be involved in the management of patients admitted for treatment of severe colitis.
• It is important to look for potentially c
orrectable exacerbating factors, such as Clostridium difficile colitis, as in the patient presented, or complicating viral infections. Intravenous cyclosporin may induce remissions in some cases of medically refractory colitis.
• However, concerns about adverse and in isolated cases even fatal effects as well as the rapid recurrence soon after discontinuation of cyclosporin have dampened the initial enthusiasm related to the use of this agent in severe inflammatory bowel disease.