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Helen O’Donovan and Valerie Byrnes discuss the case study of a patient with ulcerative colitis who presented at the ED Focus on: ulcerative colitis
months where a decision regarding need for colonoscopy would be made. Elevated faecal calprotectin Faecal calprotectin is a useful monitoring tool in inflammatory bowel disease and in identifying those who have developed or are about to suffer an acute flare in their disease. 1 If normal in asymptomatic patients, it can be reassuring. If elevated, treatment can be adjusted prior to colonoscopic investigation. Faecal calprotectin is a cytosolic protein released by neutrophils in response to inflammation. Faecal calprotectin levels have shown a good correlation with the degree of inflammation in inflammatory bowel disease. 2,3,4 Although there is no validated upper limit of normal, a faecal calprotectin level > 200-250µg/g in UC has been found to have good accuracy in predicting endoscopic activity. 5 Regular monitoring Regular disease monitoring is important in patients such as this with longstanding UC. It is also important to consider routine health maintenance and monitoring for other diseases for which patients with inflammatory bowel disease are at a higher risk. Patients with UC are at increased risk of infections due to their underlying disease, medications and the fact that they may be malnourished due to poor absorption. Routine vaccination is recommended. 6 Patients with inflammatory bowel disease are at increased risk of colorectal cancer and should undergo screening based on the extent and duration of disease. 7 Those admitted to hospital for any reason, but especially during a disease flare, should receive prophylactic anticoagulation unless contraindicated. These patients
A 67-year-old woman presented to the emergency department with a recurrence of rectal bleeding of three‑months duration after 10 years of well-controlled ulcerative colitis. The woman was initially diagnosed with ulcerative colitis (UC) in 2002. She was treated with oral therapy in the form of mesalazine 800mg once daily. Her disease was well controlled on this treatment for 10 years. During this time, her disease was monitored by assessing symptoms at regular clinic visits and follow-up with colonoscopy or sigmoidoscopy as needed. In 2012, she presented to clinic with a recurrence of per rectum (PR) bleeding, which had been ongoing for approximately three months. She denied any increase in frequency of bowel motions but did report some crampy abdominal pain. Colonoscopy revealed severe diverticular disease and biopsies of the sigmoid colon showed mild chronic active inflammation with evidence of cryptitis. Next step and management plan The dose of mesalazine was increased to 2.4g per day and the patient responded well to this. Monitoring of this patient’s disease included regular clinic visits, repeat colonoscopy and monitoring of faecal calprotectin levels. She was reviewed regularly at clinic. The dose of her medical treatment was titrated in relation to symptoms. On review in late 2018, she was taking mesalazine 800mg daily. At this time, her bowel motion frequency was stable, and she did not have bleeding PR . She did report intermittent abdominal pain. Of note, at this time, her faecal calprotectin level was elevated at 320µg/g. As a result, her medication was again increased to 1.6g daily. She was booked for review in six
Figure 1.Colonoscopy revealed severe diverticular disease and biopsies of the sigmoid colon showed mild chronic active inflammation with evidence of cryptitis
should also be monitored regularly for signs of malabsorption and side effects of treatment. Helen O’Donovan is a gastroenterology senior house officer and Valerie Byrnes is a consultant gastroenterologist at University Hospital Galway References 1.Tibble JA,Bjarnason I.Fecal calprotectin as an index of intestinal inflammation.Drugs Today (Barc) 2001; 37:85-96 2.García Sánchez Mdel V,González R, Iglesias Flores E, Gómez Camacho F,Casais Juanena L,Cerezo Ruiz A, Montero Pérez-Barquero M,Muntané J,de Dios Vega JF. [Diagnostic value of fecal calprotectin in predicting an abnormal colonoscopy] Med Clin (Barc) 2006; 127:41-6 3.Langhorst J,Elsenbruch S,Mueller T,Rueffer A,Spahn G,Michalsen A,Dobos GJ.Comparison of 4 neutrophil- derived proteins in feces as indicators of disease activity in ulcerative colitis. Inflamm Bowel Dis 2005; 11:1085-91 4.D’Haens G,Ferrante M,Vermeire S,Baert F,Noman M, Moortgat L,Geens P, Iwens D,Aerden I,Van Assche G,et al. Fecal calprotectin is a surrogate marker for endoscopic lesions in inflammatory bowel disease. Inflamm Bowel Dis 2012; 18:2218-24 5.Jason Reich,MD,Sharmeel Wasan,MD,and Francis A. Farraye,MD,MS.Vaccinating Patients With Inflammatory Bowel Disease.Gastroenterol Hepatol (NY) 2016 Sep; 12(9): 540-6 6.Song Bae,You Sun Kim.Colon Cancer Screening and Surveillance in Inflammatory Bowel Disease.Clin Endosc 2014 Nov; 47(6): 509-15 7.http://www.e-guide.ecco-ibd.eu/interventions- therapeutic/anti-tnfs#ulcerative-colitis ECCO: European Crohn’s and Colitis Organisation (Date cited 29/01/2019)
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