A 20-year-old White woman in the United States presents with tenderness in the lower left abdomen and an increased frequency of bowel movements (three per day, Bristol stool scale type 6) over the past 2 months that is often accompanied by tenesmus. The stools are loose but not watery. Her weight is stable, but she has some fatigue. She reports a 3-month history of intermittent rectal bleeding, which now occurs daily. The blood is bright red and more prominent on the tissue paper after bowel movements. She describes the pain in the lower left quadrant of her abdomen as mild to moderate cramping and localized tenderness that is not relieved after bowel movement.
The past medical history includes a recent diagnosis of uveitis, which is currently under treatment. She is a nonsmoker, has had no recent travel, and has no significant family history of gastrointestinal diseases. The patient's symptoms are causing considerable discomfort and anxiety, prompting her to seek further evaluation and management. The patient has no fever, and a normal complete blood cell count was done today in the office.
Mild-grade (or mildly active) UC is the most likely diagnosis, considering the patient's symptoms. Individuals with mild-grade UC typically experience fewer than four bowel movements per day, which might include small amounts of blood from the rectum. Patients with mild-grade UC generally do not show signs of systemic toxicity, and their C-reactive protein and erythrocyte sedimentation rate levels are usually normal, but fecal calprotectin levels can be elevated; other symptoms include mild crampy abdominal pain, tenesmus, and fatigue. Additionally, her uveitis could be an extraintestinal symptom of UC; other extraintestinal symptoms include joint pains and skin rashes.
Patients with moderate-grade UC tend to have more than four loose, bloody stools per day, and mild anemia does not require blood transfusions. Irritable bowel syndrome can cause increased bowel movements and abdominal pain but does not present with rectal bleeding, and pain tends to be relieved after a bowel movement. While Crohn's disease can exhibit similar gastrointestinal symptoms, it usually affects multiple areas of the gastrointestinal tract with segmental involvement; rectal involvement and frank bleeding are less common than in UC.
Stool testing for C (formerly Clostridium) difficile is highly recommended to help eliminate other causes of chronic diarrhea in patients suspected of having UC. Also, the polymerase chain reaction gastrointestinal pathogen test on feces can be used to evaluate for other organisms. The stool test: Fecal calprotectin can identify colonic inflammation.
Ultimately, a lower endoscopy or colonoscopy with biopsy is the preferred diagnostic method for UC. Additionally, they can assist in differentiating Crohn's disease from UC, especially early in the disease course when deciding treatment strategies and managing potential complications.
Current guidelines from the American College of Gastroenterology (ACG) do not recommend serologic antibody testing to confirm or rule out UC; abdominal radiographic testing is also not recommended for individuals with suspected UC. Finally, while a digital rectal exam can provide some information about anorectal pathology, it does not address the primary concern of identifying the underlying cause of diarrhea in this case.
The ACG recommends a combination of an oral 5-ASA agent and rectal mesalamine for patients with left-sided or extensive mildly to moderately active UC to induce remission. Further, combining rectal 5-ASA enemas with oral 5-ASA has been shown to be more effective for inducing remission than with oral 5-ASA therapy alone.
The primary treatment goal for patients with active UC is to achieve both clinical and endoscopic remission, which includes complete mucosal healing. Although the primary objectives are the resolution of symptoms (such as diarrhea, bleeding, and endoscopic healing), histologic improvement is becoming an important marker of disease remission.
For patients with mildly active left-sided UC, rectal 5-ASA enemas are recommended over rectal steroids for inducing remission. Antibiotics are generally not used unless there is a specific infectious complication, as UC is an inflammatory rather than an infectious condition.
Current guidelines strongly recommend oral 5-ASA therapy (at least 2 g/d) for maintaining remission in patients with mildly active left-sided or extensive UC. Once clinical remission is achieved, the primary aim is to prevent relapse.
Maintenance therapy is generally indicated for patients with more than one flare per year of ulcerative proctitis, all patients with ulcerative proctosigmoiditis, and those with UC extending beyond the sigmoid colon, including left-sided and extensive colitis. Given the patient's left-sided UC, oral therapy should be continued. Long-term rectal 5-ASA therapy is typically not used for patients with left-sided UC. Long-term systemic corticosteroids are not recommended in patients with UC owing to their long-term adverse effects and increased relapse risk.
Data have demonstrated that patients with UC are at a heightened risk for CRC; this population should undergo regular colonoscopy screenings based on the extent and duration of their disease. Current guidelines recommend screening and subsequent surveillance colonoscopy to assess for dysplasia in individuals with UC 8 years after diagnosis, and surveillance colonoscopies should be performed at 1- to 3-year intervals on the basis of the combined risk factors for CRC in UC and the findings on previous colonoscopies.
While fecal immunochemical test (FIT), DNA-FIT, and CT colonography are recommended as CRC prevention methods, they are not specifically for patients with diagnosed UC.
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