A 42-year-old woman comes to the office due to diarrhea. She has had 3 watery bowel movements daily for the past 7 months as well as mild, crampy abdominal pain that improves after defecation. The patient has no hematochezia, melena, or weight loss. Medical history and family history are both unremarkable. She has not traveled outside the United States. Temperature is 37.3 C (99.1 F), blood pressure is 120/78 mm Hg, pulse is 80/min, and respirations are 12/min. Physical examination shows moist mucous membranes and anicteric sclera. Heart and lung sounds are normal. The abdomen is mildly tender to palpation but nondistended. Laboratory results are as follows: A colonoscopy reveals mild erythema and small, shallow ulcers in the rectum and sigmoid colon. Which of the following would be the best next step in management?

Question

A 42-year-old woman comes to the office due to diarrhea.  She has had 3 watery bowel movements daily for the past 7 months as well as mild, crampy abdominal pain that improves after defecation.  The patient has no hematochezia, melena, or weight loss.  Medical history and family history are both unremarkable.  She has not traveled outside the United States.  Temperature is 37.3 C (99.1 F), blood pressure is 120/78 mm Hg, pulse is 80/min, and respirations are 12/min.  Physical examination shows moist mucous membranes and anicteric sclera.  Heart and lung sounds are normal.  The abdomen is mildly tender to palpation but nondistended.  Laboratory results are as follows:  A colonoscopy reveals mild erythema and small, shallow ulcers in the rectum and sigmoid colon.  Which of the following would be the best next step in management?

Quizplus · Accepted Answer

11ec25c8_d87f_be17_bc81_73770bed11bb_MD0003_00 This patient has chronic diarrhea, abdominal pain, and shallow ulcerations on colonoscopy; the most likely explanation is mild ulcerative colitis (UC). UC, a chronic inflammatory disorder of the colonic mucosa, is often characterized clinically as either mild or moderate to severe. Mild UC is defined as <4 watery bowel movements a day with intermittent hematochezia, normal inflammatory markers (eg, C-reactive protein, erythrocyte sedimentation rate), and no anemia. Colonoscopy is needed to confirm the diagnosis and usually shows inflammation and superficial ulcerations extending from the anorectum continuously to more proximal regions of the colon. Initial management for mild UC is with 5-aminosalicylic acid (5-ASA) medications (eg, mesalamine, sulfasalazine, balsalazide), which are used for both induction and maintenance therapy. Mesalamine enemas or suppositories are preferred in patients with UC confined to the rectosigmoid, whereas oral 5-ASA medications are needed for more extensive disease. Corticosteroids are typically reserved for acute disease flares or severe chronic disease and can be given topically (eg, hydrocortisone enema) or systemically (eg, prednisone). (Choice A) A gluten-free diet is used for management of celiac disease, which is characterized by small bowel intraepithelial lymphocytosis and villous blunting. Colonic ulceration does not occur. (Choice C) Metronidazole and paromomycin are used to treat Entamoeba histolytica infection, which is uncommon in the United States and typically has a subacute presentation (over several weeks) with diarrhea, hematochezia, weight loss, and possibly liver abscess development. Colonoscopy is not indicated for diagnosis, but if performed may show characteristic flask-shaped amebic ulcers. (Choice D) A total proctocolectomy with ileoanal anastomosis is the preferred surgical procedure in patients with medically refractory, severe UC; it would be inappropriate in this patient with mild UC in whom medical treatment has not been initiated. (Choice E) Tumor necrosis factor-alpha inhibitors (eg, infliximab, adalimumab, golimumab) represent first-line induction and maintenance therapy for moderate to severe UC. These patients have >6 bowel movements a day, with frequent hematochezia as well as anemia and elevated inflammatory markers. Educational objective: Mild ulcerative colitis (UC) is defined as <4 bowel movements a day, intermittent hematochezia, normal inflammatory markers, and no anemia. First-line treatment is with 5-aminosalicylic acid medications; suppositories or enemas are preferred in patients with UC limited to the rectosigmoid, whereas oral therapy is used for more extensive disease. References: AGA clinical practice guidelines on the management of mild-to-moderate ulcerative colitis. (http://www.ncbi.nlm.nih.gov/pubmed/30576644) ACG clinical guideline: ulcerative colitis in adults. (http://www.ncbi.nlm.nih.gov/pubmed/30840605)

A 42-Year-Old Woman Comes to the Office Due to Diarrhea