Ulcerative colitis
Patient Presentation:
A twenty-one year old female presents to her primary care physician with
complaints of frequent diarrhea and cramping. Her last several bouts have
included small amounts of blood, and she grew concerned enough to make an
appointment. She is 5’5’’, weighs 120 pounds, and is also complaining of low
energy. Her blood pressure is 105/70, heart rate 85, temperature 37.9,
respiratory rate 18. She states she has had no recent travel and has not
been taking any medications.
Differential List:
Crohn’s disease, ulcerative colitis, bacterial or viral infection
Diagnosis:
A CBC was drawn to evaluate for anemia due to the patient’s complaints of
lethargy and bloody stools. Her HGB was a low normal (13). Stool cultures
were taken to evaluate for an infection vs inflammatory process. White blood
cells were discovered in the stool culture, and a colonoscopy was scheduled.
The colonoscopy revealed continuous inflammation and reddened mucosa of the
recto-sigmoid colon, and biopsies were taken. Biopsies revealed inflammation
of the crypts and distortion of the crypt architecture. A diagnosis of
ulcerative colitis was made.
Treatment:
The patient was started on mesalazine to suppress the inflammatory response
and alleviate her cramping pain. The patient began a food diary, noting
foods that seemed to increase her symptoms.
Outcome:
The patient’s ulcerative colitis went into remission during her course of
mesalazine, and she remains on a maintenance dose. Her food journal revealed
a problem with dairy and caffeinated beverages, and she has cut them out of
her diet, supplementing with a vitamin D and calcium vitamin daily.