IBD Case of the Month: 19 year old white male with hematochezia

1. IBD Case of the Month:19 year old white male with hematochezia Developed by the CCFA Nurse and Advanced Practice Committee Author: LarylR Riley MSN, APRN, CGRN GI Specialists Inc. Westerly, Rhode Island

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3. Objectives • Identify differential diagnosis of hematochezia • Explain how to diagnose IBD • Discuss treatments and their side effects used to treat moderate to severe disease • Identify important pertinent patient education

4. Introduction/Background 19 year old white male hospitalized with 3 week history of bloody diarrhea, which had progressed to 15 stools per day. He also had nausea, vomiting, and abdominal pain (which occasionally improved after bowel movements).

5. What additional information will be helpful? • What is his past medical history? • Any recent travel, antibiotics? • What medications does he take? • Any weight loss? • Any lake water exposure and/or pets (reptiles/farm animals)? • Any family history of IBD or other colon/GI issues?

6. Review of Systems (ROS)Consider the red flags • General – 15 lb weight loss, decreased appetite, fever and chills • Skin – negative for skin rash or easy bruising • ENT – negative, denies mouth sores • Respiratory – denies shortness of breath but complains of cough • Cardiovascular – negative • Genitourinary – negative • Musculoskeletal – negative • Hematologic/Lymphatic – negative • Neurologic – complains of headaches • Endocrine - negative • Psychosocial – positive for anxiety, denies depression

7. Vital Signs • Temperature: 99 F • Pulse: 96 • Respirations: 18 • BP: 124/54 • Weight: 88.5 kg/194.7 lbs

8. Physical Exam • General: no acute distress • Skin: non icteric (no rashes, lesions) • Mouth: no oral ulcers • Nodes: negative, no cervical adenopathy • HEENT: mucous membranes moist • Neck: Supple. No thyromegaly. No carotid bruits. • Chest: clear • Back: no CVA tenderness • Cardiac: regular rate and tachycardia • Abdomen: Soft, non distended, normal active bowel sounds, LLQ tender to palpation, no guarding or rebound. No palpable massesor organomegaly. • Rectal: Digital exam, bloody mucus • Extremities: no edema • Neurological: no focal deficits

9. Previous Workup • Stool studies – ordered by Primary Care Provider: • Stool sample • Clostridium difficle- negative • Salmonella, Shigella, E Coli – negative • Giardia- negative • Cryptosporidium- negative

10. Do you have cause for concern based on physical exam & previous workup? • No concern • Only minimal concern • Significant concern • Major concern indicating need for admission

11. Do you have a Differential Diagnosis? • Infectious Causes • Diverticular Bleeding • Ischemic Colitis • Inflammatory Bowel Disease • Proctitis • Drug Induced Cause • Colorectal neoplasia • Meckel’s Diverticulum

12. What should be ordered for workup? • Laboratory investigations for: CBC, CMP, ESR, CRP, Blood Cultures, B12, Iron Studies, TSH, Amylase/Lipase • Blood cultures • Colonoscopy • Upper endoscopy • Abdominal image study : CT scan of the abdomen/pelvis or ultrasound of abdomen • Chest x-ray • Urine routine and culture • Sputum sample

13. Laboratory Results • WBC : 7.5 K/uL • Hgb : 14.7 Gm • Hct : 42.3 % • Platelets: 208 K/uL • Sodium: 139 mmol/L • Potassium : 3.9 mmol/L • Chloride: 101 mmol/L • Albumin : 3.2 g/dLLow • CRP : 3.6 mg/L High

14. Results: Colonoscopy • Moderate to severe proctosigmoiditis • Localized continuous erythema, erosion and granularity with stigmata of recent bleeding were noted in the rectum, distal sigmoid colon and mid-sigmoid colon. • Biopsies: • Sigmoid colon mucosa with moderate to severe chronic active colitis. • Rectum with severe chronic active colitis. • Ascending, transverse and descending colon without evidence of active colitis. • No evidence of dysplasia or granulomas. • Histologic features support ulcerative colitis.

15. Colonoscopy Sigmoid Colon

16. What is your Diagnosis? • Ulcerative Colitis

17. What is your plan of care? • Start with oral 5 ASA product • Delzicol 400 mg 4 tablets 3 times a day • Lialda 1.2 Gm X4 • Apriso 0.375 mg X4 • Add rectal 5 ASA product • Mesalamine (Canasa) suppositories • Mesalamine (Rowasa) enemas Click here to learn more Click here to learn more

18. Follow up in the Office Two Weeks Later • The patient was discharged from the hospital on mesalamine (delzicol) 400 mg, 4 tablets three times a day. • At follow up, reports doing a little better, but: • Having 6-10 watery, bloody stools daily • Lower abdominal cramping (sometimes sharp) • Pain at times worse after stooling, may be associated with nausea, but previous emesis resolved. Has occasional rectal pain. • Feels bloated • Denies odynophagia, dysphagia, heartburn or melena

19. Now what? • Continue mesalamine (Delzicol) • Stop mesalamine (Delzicol) • Add topical preparation • Add steroids/budesonide • Prepare for stronger medical therapy

20. Treatment • Stop mesalamine (Delzicol) • Add budesonide 9 mg a day (Uceris) • Provide patient education for ulcerative colitis • Refer patient to CCFA website • Schedule follow up visit two weeks later

21. Follow up Visit Two Weeks Later • Although somewhat better, he still reports abdominal pain that resolves after a bowel movement, nausea without emesis and his stools are less frequent (5 times a day on average with less blood). • Today he has noticed increased frequency, tenesmus and blood.

22. Which would you choose? • Begin budesonide (Uceris) 9 mg once a day • Stop mesalamine (Delzicol) • Budesonide (Entocort) • Antibiotics • Dicyclomine (Bentyl)

23. One month later This patient's mother called the office reporting that after taking the mesalamine (Rowasa) enema he developed abdominal pain associated with nausea and shaking. The next morning he vomited, but since then felt better. He did not want to try the enema again. Over the past week, has been feeling better,averaging 2 formed bowel movements daily. Sometimes the stool is loose, but there has been less blood, every other day. The blood is on the tissue paper, no longer in the water. Has occasional cramps before bowel movement, but improves after stooling. Denies rectal pain and melena, denies odynophagia, dysphagia and heartburn. Has occasional nausea, but denies vomiting. Occasional postprandial bloating.

24. What is next step? • Stop mesalamine (Rowasa), it was poorly tolerated and the patient is not interested in restarting • Stop budesonide (Uceris) after completing a 2 month course • Add once a day mesalamines product • Apriso 0.375 mg X4 was started • Plan to see patient back in 2 months

25. One month later • The patient was seen as an urgent sick visit. • He did well until the budesonide (Uceris) was stopped as he was instructed. For 2 weeks now the patient has return of lower abdominal cramping, rectal bleeding and bowel frequency up to 4 times a day. The diarrhea does not wake him up at night. He had a fever Saturday night with headache and nausea. His mother had the flu.

26. What is your plan of care? • Stool samples • For infection • Fecal calprotectin • Continue Apriso • Restart budesonide (Uceris) • Use Prednisone instead • Add Immunomodulator (6MP/Azathioprine) • Consider biologic

27. Starting the Biologic • The patient became very proactive; after investigating all the biologic choices he choose golimumab (Symponi) • His child hood vaccines were UTD (including Hepatitis B and MMR) • TB testing and CXR were negative • He was advised to get Pneumonia vaccine and yearly influenza injectable (avoid live vaccines) • Upper respiratory infections are the most common reported side effects • He was taught self-injection in the office

28. Adverse Events Associated with Biologics • Upper respiratory infections 16% • Viral infections 5% • Bronchitis 2% • Superficial fungal infections 2% • Sinusitis 2% • General disorders and site reactions 6% • Vascular disorders 3% • Nervous system disorders 2% • Gastrointestinal disorders 1% Golimumab(Simponi) package insert revised 11/2013

29. Summary • This young male patient presented with fever, anorexia, weight loss and frequent bloody diarrhea. • Colonoscopy and biopsies remarkable for ulcerative colitis, left sided. • He did not respond to initial therapy with oral and topical mesalamines. Nausea and vomiting with mesalamine (Rowasa) enemas. • Budesonide (Uceris) was started but he flared each time it was stopped. • Golimumab (Simponi) was started using self-injecting pen and prefilled syringe, and within 2 weeks the patient was back to baseline.

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