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