Dr Vikrant Sibartie FRCP (Ireland), CSCST Consultant Internal Medicine and Gastroenterology
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Dr Vikrant Sibartie FRCP (Ireland), CSCST Consultant Internal Medicine and Gastroenterology 11 year old girl Admitted to Apollo Bramwell Hospital(Paediatrics) with: ‐Periumbilical abdominal pains for 3 days Getting more severe ‐ Diarrhoea 4 X/day ‐ Vomited twice on day of admission Eaten in Steers restaurant 3 days prior to onset of symptoms Examination: Very tender central and lower abdomen US abdomen: normal Started on IV Rocephin and Flagyl Bloody diarrhoea up to 8 times daily CT abdomen: Features of Right sided colitis Persistent diarrhoea Rocephin stopped, changed to Ciprofloxacin Ongoing bloody diarrhoea up to 10 times daily Consultation to Gastroenterology Colonoscopy: Pancolitis Stools: Negative for Rotavirus and Adenovirus No Salmonella or Shigella Colon Biopsies: Inflammatory Bowel Disease, more in keeping with Ulcerative Colitis Started on IV Hydrocortisone 100 mg TDS Mesalazine (Asacol) 400 mg tds Bloody diarrhoea up to 10 times daily and abdominal pains persist CRP=38 What next? Infliximab (Remicade) infusion started Improvement of diarrhoea to 5 times daily within 2 days Less bloody Abdominal pains improved Colonoscopy: Improvement of colitis in left colon Mild ‘backwash ileitis’ terminal ileum Normal distal ileum Pseudopolyps in Caecum and ascending colon Semi‐formed stools up to 5 times daily, blood only intermittently. Patient discharged 3 weeks post discharge: Bloody diarrhoea and abdominal pains recur 2nd infusion Infliximab given Azathioprine 50 mg started 3rd infusion Infliximab 4 weeks later Does well at follow up 27 year old man Englishman, residing in Seychelles Weight loss 20 kg in 4 years Bloody diarrhoea 10 times daily Sigmoidoscopy 2 years prior in Seychelles: Ulcers and Pseudopolyps Biopsies: Non‐specific inflammation Started on Mesacolon there, without much improvement Comes to ABH, as no improvement Colonoscopy:Patchy inflammation and ulceration whole colon Sigmoid pseudopolyps Strictured Transverse colon Normal terminal ileum Descending Colon Transverse colon Terminal ileum Biopsies: Crohn’s disease IV Hydrocortisone 100 mg QDS Azathioprine 50 mg started High calorie diet Hb=9.0 Iron infusion given (Venofer) Improves, and discharged on reducing dose Prednisolone PO Back in Seychelles Intermittent attacks of abdominal cramps and diarrhoea for 2 months Comes back to ABH Started on Infliximab Maintenance program every 8 weeks Remains well 9 months later: does not come for Infliximab, worsening abdominal pains 10 weeks post Infliximab Comes back to Mauritius Looks unwell Severe tenderness left abdomen CT scan abdomen performed Left‐sided Colonoscopy Gets better with Infliximab, but without complete remission Difficulty in continuing INF due to financial constraints Goes to the UK Partial left colectomy, with transverse colostomy Planned to re‐anastomose once rectum heals Anti‐TNF alpha therapy is now part of our armamentarium against IBD Useful in fulminant colitis Induces and maintains remission where all else has failed Reduces total colectomy rate
