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IBD Case of the Month:
19 year old white male with hematochezia
Developed by the CCFA Nurse and Advanced Practice Committee
Author: Laryl R Riley MSN, APRN, CGRN
GI Specialists Inc.
Westerly, Rhode Island
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Objectives
• Identify differential diagnosis of hematochezia
• Explain how to diagnose IBD
• Discuss treatments and their side effects used to
treat moderate to severe disease
• Identify important pertinent patient education
Introduction/Background
19 year old white male hospitalized with 3 week
history of bloody diarrhea, which had progressed
to 15 stools per day. He also had nausea,
vomiting, and abdominal pain (which occasionally
improved after bowel movements).
What additional information will be
helpful?
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What is his past medical history?
Any recent travel, antibiotics?
What medications does he take?
Any weight loss?
Any lake water exposure and/or pets
(reptiles/farm animals)?
• Any family history of IBD or other colon/GI
issues?
Review of Systems (ROS)
Consider the red flags
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General – 15 lb weight loss, decreased appetite, fever and chills
Skin – negative for skin rash or easy bruising
ENT – negative, denies mouth sores
Respiratory – denies shortness of breath but complains of cough
Cardiovascular – negative
Genitourinary – negative
Musculoskeletal – negative
Hematologic/Lymphatic – negative
Neurologic – complains of headaches
Endocrine - negative
Psychosocial – positive for anxiety, denies depression
Vital Signs
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Temperature: 99 F
Pulse: 96
Respirations: 18
BP: 124/54
Weight: 88.5 kg/194.7 lbs
Physical Exam
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General: no acute distress
Skin: non icteric (no rashes, lesions)
Mouth: no oral ulcers
Nodes: negative, no cervical adenopathy
HEENT: mucous membranes moist
Neck: Supple. No thyromegaly. No carotid bruits.
Chest: clear
Back: no CVA tenderness
Cardiac: regular rate and tachycardia
Abdomen: Soft, non distended, normal active bowel sounds, LLQ tender to
palpation, no guarding or rebound. No palpable masses or organomegaly.
Rectal: Digital exam, bloody mucus
Extremities: no edema
Neurological: no focal deficits
Previous Workup
• Stool studies – ordered by Primary Care Provider:
– Stool sample
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Clostridium difficle- negative
Salmonella, Shigella, E Coli – negative
Giardia- negative
Cryptosporidium- negative
Do you have cause for concern based on
physical exam & previous workup?
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No concern
Only minimal concern
Significant concern
Major concern indicating need for admission
Do you have a Differential
Diagnosis?
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Infectious Causes
Diverticular Bleeding
Ischemic Colitis
Inflammatory Bowel Disease
Proctitis
Drug Induced Cause
Colorectal neoplasia
Meckel’s Diverticulum
What should be ordered for workup?
• Laboratory investigations for: CBC, CMP, ESR, CRP,
Blood Cultures, B12, Iron Studies, TSH, Amylase/Lipase
• Blood cultures
• Colonoscopy
• Upper endoscopy
• Abdominal image study : CT scan of the abdomen/pelvis
or ultrasound of abdomen
• Chest x-ray
• Urine routine and culture
• Sputum sample
Laboratory Results
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WBC : 7.5 K/uL
Hgb : 14.7 Gm
Hct : 42.3 %
Platelets: 208 K/uL
Sodium: 139 mmol/L
Potassium : 3.9 mmol/L
Chloride: 101 mmol/L
Albumin : 3.2 g/dL Low
CRP : 3.6 mg/L High
Results: Colonoscopy
• Moderate to severe proctosigmoiditis
– Localized continuous erythema, erosion and granularity with
stigmata of recent bleeding were noted in the rectum, distal
sigmoid colon and mid-sigmoid colon.
• Biopsies:
– Sigmoid colon mucosa with moderate to severe chronic active
colitis.
– Rectum with severe chronic active colitis.
– Ascending, transverse and descending colon without
evidence of active colitis.
– No evidence of dysplasia or granulomas.
– Histologic features support ulcerative colitis.
Colonoscopy
Sigmoid Colon
What is your Diagnosis?
• Ulcerative Colitis
What is your plan of care?
• Start with oral 5 ASA product
– Delzicol 400 mg 4 tablets 3 times a day
– Lialda 1.2 Gm X4
– Apriso 0.375 mg X4
• Add rectal 5 ASA product
– Mesalamine (Canasa) suppositories
– Mesalamine (Rowasa) enemas
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Follow up in the Office Two Weeks Later
• The patient was discharged from the hospital on mesalamine
(delzicol) 400 mg, 4 tablets three times a day.
• At follow up, reports doing a little better, but:
– Having 6-10 watery, bloody stools daily
– Lower abdominal cramping (sometimes sharp)
– Pain at times worse after stooling, may be associated with
nausea, but previous emesis resolved. Has occasional
rectal pain.
– Feels bloated
– Denies odynophagia, dysphagia, heartburn or melena
Now what?
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Continue mesalamine (Delzicol)
Stop mesalamine (Delzicol)
Add topical preparation
Add steroids/budesonide
Prepare for stronger medical therapy
Treatment
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Stop mesalamine (Delzicol)
Add budesonide 9 mg a day (Uceris)
Provide patient education for ulcerative colitis
Refer patient to CCFA website
Schedule follow up visit two weeks later
Follow up Visit Two Weeks Later
• Although somewhat better, he still reports
abdominal pain that resolves after a bowel
movement, nausea without emesis and his
stools are less frequent (5 times a day on
average with less blood).
• Today he has noticed increased frequency,
tenesmus and blood.
Which would you choose?
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Begin budesonide (Uceris) 9 mg once a day
Stop mesalamine (Delzicol)
Budesonide (Entocort)
Antibiotics
Dicyclomine (Bentyl)
One month later
This patient's mother called the office reporting that after taking the
mesalamine (Rowasa) enema he developed abdominal pain
associated with nausea and shaking. The next morning he vomited, but
since then felt better. He did not want to try the enema again. Over the
past week, has been feeling better, averaging 2 formed bowel
movements daily. Sometimes the stool is loose, but there has been
less blood, every other day. The blood is on the tissue paper, no longer
in the water. Has occasional cramps before bowel movement, but
improves after stooling. Denies rectal pain and melena, denies
odynophagia, dysphagia and heartburn. Has occasional nausea, but
denies vomiting. Occasional postprandial bloating.
What is next step?
• Stop mesalamine (Rowasa), it was poorly
tolerated and the patient is not interested in
restarting
• Stop budesonide (Uceris) after completing a 2
month course
• Add once a day mesalamines product
• Apriso 0.375 mg X4 was started
• Plan to see patient back in 2 months
One month later
• The patient was seen as an urgent sick visit.
• He did well until the budesonide (Uceris) was stopped as
he was instructed. For 2 weeks now the patient has
return of lower abdominal cramping, rectal bleeding and
bowel frequency up to 4 times a day. The diarrhea does
not wake him up at night. He had a fever Saturday night
with headache and nausea. His mother had the flu.
What is your plan of care?
• Stool samples
– For infection
– Fecal calprotectin
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Continue Apriso
Restart budesonide (Uceris)
Use Prednisone instead
Add Immunomodulator (6MP/Azathioprine)
Consider biologic
Starting the Biologic
• The patient became very proactive; after investigating all
the biologic choices he choose golimumab (Symponi)
• His child hood vaccines were UTD (including Hepatitis B
and MMR)
• TB testing and CXR were negative
• He was advised to get Pneumonia vaccine and yearly
influenza injectable (avoid live vaccines)
– Upper respiratory infections are the most common
reported side effects
• He was taught self-injection in the office
Adverse Events Associated with
Biologics
Upper respiratory infections
16%
Viral infections
5%
Bronchitis
2%
Superficial fungal infections
2%
Sinusitis
2%
General disorders and site reactions
6%
Vascular disorders
3%
Nervous system disorders
2%
Gastrointestinal disorders
1%
Golimumab (Simponi) package insert revised 11/2013
Summary
• This young male patient presented with fever, anorexia,
weight loss and frequent bloody diarrhea.
• Colonoscopy and biopsies remarkable for ulcerative
colitis, left sided.
• He did not respond to initial therapy with oral and topical
mesalamines. Nausea and vomiting with mesalamine
(Rowasa) enemas.
• Budesonide (Uceris) was started but he flared each time
it was stopped.
• Golimumab (Simponi) was started using self-injecting
pen and prefilled syringe, and within 2 weeks the patient
was back to baseline.
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