Ulcerative colitis - after severe first disease manifestation
This 18-year-old white female reported onset of blood diarrhea four months previously. Outpatient colonoscopy revealed ulcerative colitis with moderate disease activity. The patient received 5-aminosalicylic acid (5-ASA) and prednisolone, but experienced a worsening of clinical symptoms. The patient was admitted to the hospital and started on cyclosporine in addition to the previously instituted prednisolone. This treatment also failed to provide any noticeable clinical improvement. CRP remained high, the patient reported abdominal pain and continued diarrhea, with minor admixture of blood. The patient developed anemia requiring transfusion. Clinically, there was no guarding and only minor pain on pressure in the abdomen. Because surgery was being contemplated, the patient underwent a further endoscopy (high colonoscopy) with very careful insufflation and careful advance of the instrument.
The examination begins in the terminal ileum. There are numerous ulcerations that have undergone significant re-epithelialization. Similar changes are seen in the entire colon. The upper sigmoid shows a ladder-like arrangement of ulcerations. Histological examination confirmed the diagnosis of ulcerative colitis.
Over the previous two weeks, ultrasound failed to demonstrate any improvement. The gastroenterological team arrived at the decision to recommend proctocolectomy. Intraoperatively, there were covered perforations. It is thought that the covered perforations had occurred during the outpatient treatment of a severe disease flare and between the first and second colonoscopy. Histological examination of the surgical specimen confirmed the diagnosis of ulcerative colitis.