Brenda: a case study for acute severe ulcerative colitis
Professor Gibson presented the case of ‘Brenda’, aged 27, who works in marketing and lives with her partner.
3:48 – Role of intestinal ultrasound
11:40 – Response predictors
17:01 – Management of acute severe ulcerative colitis
30:51 – Accessing REMICADE on the PBS for acute severe ulcerative colitis
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Brenda presented with a 6-month history of rectal bleeding. Moderately-severe UC to 20 cm was diagnosed and she was treated with oral and rectal mesalazine, which led to complete resolution of her symptoms.
Brenda re-presented with rectal bleeding accompanied by diarrhoea and abdominal pain. Investigations revealed marked faecal loading on plain abdominal X-ray, disease to 30 cm on abdominal ultrasound and sigmoidoscopy, no CMV on biopsy, and iron-deficiency anaemia, but no small bowel abnormalities on magnetic resonance enterography. Her severe distal colitis was treated with oral prednisolone and mesalazine, and mercaptopurine 50 mg/day was initiated. She was also treated with laxatives to relieve her constipation, and an iron infusion.
Brenda’s symptoms remained relatively well-controlled throughout 2014: she sometimes had rectal bleeding but rarely had abdominal pain. Prednisolone was tapered and mercaptopurine was continued: the 6TGN level was in the lower part of the therapeutic range, being 271 pmol/8×108 RBC. She was in the process of being ‘worked up’ for the possibility of biologic therapy, for example by reviewing her vaccination status.
Brenda experienced a flare despite prior efforts to optimise her therapy. She was significantly unwell, experiencing marked abdominal pain, >10 bowel actions/day, elevated CRP (145 mg/L), low albumin (20 g/L) and a BMI of 17.2 kg/m2 following a 10% loss of body weight. A plain abdominal X-ray showed faecal loading, and intestinal ultrasound showed 30 cm of active disease with faecal loading and mild ileal distension. Faecal microbiology was unremarkable.
IV corticosteroids were commenced but, by day 3, she still had 8 bowel actions with blood. However, CRP had declined markedly to 23 mg/L. Infliximab 5 mg/kg was given on day 4, and by day 6 there were only 3 bowel actions with minimal blood. CRP was 8 mg/L and albumin 24 g/L. Brenda was discharged on day 7. On review 2 weeks later, Brenda was well, had no rectal bleeding, and received a second dose of infliximab.
The following points arose during discussion of the case with the expert panel and the audience.
- In the experience of one expert participating in the discussion, intestinal ultrasound can distinguish transmuraland mucosal inflammation in inflammatory bowel disease, based on a loss of discrete layering or stratification of the bowel wall in addition to thickened mucosa. It can also distinguish, in most cases, between a reactive change resulting from the proximity of the terminal ileum to an inflamed rectum and true terminal ilealdisease.
- Brenda may eventually benefit from colectomy, but she is not yet fit enough for surgery. Restoring her health, in addition to controlling her symptoms, is the immediate priority.
- Low albumin and weight loss should prompt a comprehensive nutritional review, including assessment of her current diet. Some patients with inflammatory bowel disease adopt counterproductive diets in an attempt to control their symptoms. Low albumin levels are a strong predictor of a poor prognosis.1 Brenda may benefit from total parenteral nutrition given her current symptoms and poor nutritional status.
- Effective treatment of colitis, which can cause pain and bloating regardless of intestinal transit time, may reduce Brenda’s symptoms of proximal constipation.
- At least 25% of patients who have an episode of acute severe UC will experience a recurrent episode.2 Maintenance infliximab therapy should be considered, noting that PBS restrictions allow only one induction course per patient. The panel recommended combination of infliximab with an immunosuppressant, and longer-term use of mercaptopurine in combination with 5-ASA.