ulcerative colitis
TRANSCRIPT
ULCERATIVE COLITIS-
REFRACTORY {LEFT SIDED COLITIS}
D O N E Y J O S E P H P H A R M D I N T E R N
Ulcerative colitis is a chronic inflammation of the large intestine (colon). The colon is the part of the digestive system where water is removed from undigested material, and the remaining waste material is stored
Left-sided colitis: As the name suggests, inflammation extends from the rectum up through the sigmoid and descending colon, which are located in the upper left part of the abdomen. Signs and symptoms include bloody diarrhoea, abdominal cramping and pain on the left side
REASON FOR ADMISSION
History of loose stools since 1 week{8 times daily}, associated with blood mixed stools
Patient is also a k/c/o of ulcerative colitis since 1.5 years{drug induced}
No history of fever , anorexia , weight loss, vomiting, etc..
NSAID induced
No pallor/icterus
PREVIOUS REPORTS..
10/01/2013 : histopathology report of colon was Active ulcerative colitis
On 1/09/2013: colonoscopy report was: ulcerative colitis left sided
On 17/10/2013: biopsy report was : acute ulcerative colitis
DAY 1..
Bp:110/70 mmhg pulse: 78bpm
CVS
RS NAD
CNS
Adv:HB,ESR,PCV,TC,DC,RBS,PBS,SE,TSH,LFT,ECG,Anti-HCV,Elisa
Plan for colonoscopy tomorrow
Hematology
Hb- 9.3% ( 13-16g%)
WBC- 8200 (4000-11,000) cells/mm3
DLC- N- 57% E- 04%
B- 01% L-37%
M- 01%
ESR- 50 mm/hr (0-10mm/hr)
Anti-HCV,ELISA- negative
PBS: Microcytic hypochromic anemia
Biochemistry
RBS- 77 mg/dl
Electrolytes-
Sodium- 145 mmol/l
Potassium- 4.2mmol/l
Chloride- 99 mmol/l
Thyroid profile
T3: 1.28 (0.60- 1.81ng/ml)
T4: 7.7 ( 4.5- 10.9 mcg/ml)
TSH:0.69 (0.35- 5.5 IU/ML)
LAB REPORTS
LFT:( mg/dl) stool microscopy: AST: 15 (0-40) No inflammatory cells and parasite
ALT: 12 (0-40) ova or cyst are not seen.
ALP: 204 (40-376) ECG: WNL
Albumin: 3.4 ( 3.5-5)
MEDICATIONS..
Inj hydrocortisone iv q6h 100 mg PROCTOCLYSIS-ENEMA 1-0-1Capsule VSL3 1-0-0Tablet mesalamine po 1.2mg 2-0-0Tablet pantoprazole po 40mg 1-0-0Tablet eldicet{Pinaverium} po 50 mg 1-0-1
DAY 2..
Bp:110/70 mmhg pulse: 80bpm
CVS
RS NAD
CNS
Patient passed stools mixed with blood, patient advised for PROCTOCLYSIS-ENEMA for colonoscopy
Colonoscopy report: IBD- proctosigmoiditis
Ulcerative proctitis. In this form of ulcerative colitis, inflammation is confined to the area closest to the anus (rectum), and for some people, rectal bleeding may be the only sign of the disease
Proctosigmoiditis. This form involves the rectum and the lower end of the colon, known as the sigmoid colon..
DAY 3.
BP: 120/80mmhg pulse: 78bpm
CVS
RS NAD
CNS
P/A-soft , patient complains of blood mixed stools
ADV: CST
DAY 4.
Bp:120/80bpm pulse: 80bpm
CVSRS NADCNSFreequency of loose stools decreased, decreased amount of blood in the
stoolADV:to stop Inj hydrocortisone Started tablet Methylprednisolone 16 mg po 2-0-0Tablet calcium carbonate 500 mg po 0-1-0
DAY 5..
Bp: 110/70mmhg pulse: 78bpm
CVSRS NADCNSP/A-soft, patient complaints of semi solid stools not
associated with blood{ 3-4} episodesADV:CST
DAY 6..
Bp: 120/80 mmhg pulse: 80bpm
CVS
RS NAD
CNS
Patient did not have any complaints of loose stools, no history of blood in the stool
ADV: CST
PHARMACEUTICAL CARE PLAN
Subjective evidence
• Loose stools associated with blood
• k/c/o ulcerative colitis
Objective evidence• Colonoscopy
report• Histopathology
report• Biopsy report
FINAL DIAGNOSIS
Based on subjective and objective evidence ulcerative colitis with refractory – left sided colitis
GOALS OF TREATMENT
Terminate the acute attack and induce clinical remission.
Maintain remission during quiescent symptom-free periods.
Control symptoms during symptomatic periods.
Prevent or control complications.
Avoid surgery, if possible.
Use the most cost-effective drug treatment.
Maintain or improve quality of life.
TREATMENT OPTIONS
Aminosalicylates:sulfasalazine {3-4g/day}
Mesalamine
Corticosteriods: hydrocortisone{300mg/day}, methyl prednisolone{20-60mg/day}
Immunomodulators: Azathioprine{2-3mg/kg/day} ,6-mercaptopurine{1-1.5mg/kg} , Methotrexate{25mg/week},
Antibiotics:Metronidazole
WHEN SURGERY INDICATED????
1. Fails to respond to medical management acutely or chronically,
2. Develops uncontrollable drug-related complications,
3. Experiences impaired quality of life from the disease or its drug therapy,
4. Develops carcinoma of the rectum or colon.
SURGICAL METHODS..Total proctocolectomy with ileostomy :Total
proctocolectomy with ileostomy is surgery to remove all of the colon (large intestine) and rectum. Then a hole in abdomen, called a stoma, is made. Waste will move from the small intestine, out the stoma, and into a plastic ostomy bag.
ILEAL POUCH ANAL ANASTOMOSIS
The most common procedure for ulcerative colitis is pelvic pouch or ileal pouch anal anastomosis (IPAA). colon and rectum will be removed. A new rectum, called a J-pouch, will be fashioned out of small intestine. This type of surgery allows to have bowel movements .
CONTINENT ILEOSTOMY:
The least common surgery for UC is continent ileostomy. Also called the Kock pouch, it's a very technical surgery.. During the procedure colon and rectum are removed. Small intestine is used to create a holding place (reservoir) for waste that will be drained from a valve in abdomen
GOALS ACHIEVED
No more episodes of loose stools and bloody stools by day 6
PROBLEMS IDENTIFIED
Untreated anemia
MONITORING PARAMETERS
Weight
CBC
Colonoscopy
Glucose levels
Electrolytes level
PATIENT COUNSELLING
About disease: signs and symptoms risk factors complications
About medications: medication adherence Possible side effects
LIFE STYLE MODIFICATIONS:
A well-balanced, nutritious diet can help maintain health and a normal body weight.
Pain medications that contain nonsteroidal antiinflammatory drugs (NSAIDS), such as ibuprofen and naproxen ,are not usually recommended