ulcerative colitis

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  • 1.ULCERATIVE COLITISREFRACTORY {LEFT SIDED COLITIS} DONEY JOSEPHPHARMD INTERN

2. 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 3. 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 4. 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 5. 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 6. DAY 1.. Bp:110/70 mmhgpulse: 78bpmCVS RS NAD CNS Adv:HB,ESR,PCV,TC,DC,RBS,PBS,SE,TSH,LFT,ECG,AntiHCV,Elisa Plan for colonoscopy tomorrow 7. LAB REPORTS Hematology Hb- 9.3% ( 13-16g%)Biochemistry RBS- 77 mg/dlWBC- 8200 (4000-11,000) cells/mm3ElectrolytesSodium- 145 mmol/l Potassium- 4.2mmol/l Chloride- 99 mmol/lDLC- N- 57% B- 01% M- 01%E- 04% L-37%ESR- 50 mm/hr (0-10mm/hr) Anti-HCV,ELISA- negative PBS: Microcytic hypochromic anemiaThyroid 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) 8. LFT:( mg/dl) AST: 15 (0-40)stool microscopy: No inflammatory cells and parasiteALT: 12 (0-40)ova or cyst are not seen.ALP: 204 (40-376)ECG: WNLAlbumin: 3.4 ( 3.5-5) 9. MEDICATIONS..Inj hydrocortisone iv q6h 100 mg PROCTOCLYSIS-ENEMA 1-0-1 Capsule VSL3 1-0-0 Tablet mesalamine po 1.2mg 2-0-0 Tablet pantoprazole po 40mg 1-0-0 Tablet eldicet{Pinaverium} po 50 mg 1-0-1 10. DAY 2.. Bp:110/70 mmhg CVS RS NAD CNSpulse: 80bpmPatient passed stools mixed with blood, patient advised for PROCTOCLYSIS-ENEMA for colonoscopy Colonoscopy report: IBD- proctosigmoiditis 11. 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 diseaseProctosigmoiditis. This form involves the rectum and the lower end of the colon, known as the sigmoid colon.. 12. DAY 3.BP: 120/80mmhg pulse: 78bpm CVS RS NAD CNS P/A-soft , patient complains of blood mixed stools ADV: CST 13. DAY 4. Bp:120/80bpmpulse: 80bpmCVS RS NAD CNS Freequency of loose stools decreased, decreased amount of blood in the stool ADV:to stop Inj hydrocortisone Started tablet Methylprednisolone 16 mg po 2-0-0 Tablet calcium carbonate 500 mg po 0-1-0 14. DAY 5.. Bp: 110/70mmhgpulse: 78bpmCVS RS NAD CNS P/A-soft, patient complaints of semi solid stools not associated with blood{ 3-4} episodes ADV:CST 15. DAY 6..Bp: 120/80 mmhgpulse: 80bpmCVS RS NAD CNS Patient did not have any complaints of loose stools, no history of blood in the stool ADV: CST 16. PHARMACEUTICAL CARE PLAN 17. Subjective evidence Loose stools associated with blood k/c/o ulcerative colitisObjective evidence Colonoscopy report Histopathology report Biopsy report 18. FINAL DIAGNOSISBased on subjective and objective evidence ulcerative colitis with refractory left sided colitis 19. 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. 20. TREATMENT OPTIONS Aminosalicylates:sulfasalazine {3-4g/day} Mesalamine Corticosteriods: hydrocortisone{300mg/day}, methyl prednisolone{20-60mg/day} Immunomodulators: Azathioprine{2-3mg/kg/day} ,6mercaptopurine{1-1.5mg/kg} , Methotrexate{25mg/week}, Antibiotics:Metronidazole 21. 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. 22. 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. 23. 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 . 24. 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 25. GOALS ACHIEVEDNo more episodes of loose stools and bloody stools by day 6 26. PROBLEMS IDENTIFIEDUntreated anemia 27. MONITORING PARAMETERS Weight CBC Colonoscopy Glucose levels Electrolytes level 28. PATIENT COUNSELLING About disease: signs and symptoms risk factors complicationsAbout medications:medication adherence Possible side effects 29. 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

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