GI Follow up - IBD patient

The patient is a 34-year-old female, Ms. Sarah Jenkins, attending a follow-up consultation in the Gastroenterology clinic via video call. She was referred by her GP for ongoing management of her Inflammatory Bowel Disease. IBD PROFILE Diagnosis * Ulcerative Colitis, pancolitis, diagnosed in October 2018 by Dr. Eleanor Vance at St. Jude's Hospital. Summary of course * In October 2018, diagnosed with Ulcerative Colitis after presenting with bloody diarrhoea and abdominal pain. Initial treatment with oral Mesalazine 2.4g daily. FCP result was 1200 µg/g. * In April 2019, experienced a moderate flare, requiring a course of oral Prednisolone 40mg tapering over 8 weeks. Mesalazine dose increased to 4.8g daily. * In July 2020, developed steroid dependency. Commenced on Azathioprine 100mg daily. FCP result 450 µg/g. * In January 2021, Azathioprine discontinued due to persistent abnormal LFTs. Started on Vedolizumab 300mg IV at weeks 0, 2, 6, then every 8 weeks. Vedolizumab trough level 28 µg/mL. * In March 2022, remained in clinical remission. FCP result 75 µg/g. * In November 2023, reported mild increase in stool frequency, no blood. Vedolizumab trough level 25 µg/mL. FCP result 150 µg/g. Current Treatments: * Vedolizumab 300mg IV every 8 weeks (last dose 15 October 2024) * Mesalazine 4.8g daily (oral) Preventative * Vaccinations: * Influenza vaccine: October 2024 * Pneumococcal vaccine: September 2022 * Tetanus/Diphtheria/Pertussis: April 2021 * Infection screening: * HBV surface antigen: Negative (July 2020) * HCV antibody: Negative (July 2020) * TB Quantiferon Gold: Negative (July 2020) * CXR: Clear (July 2020) * Nutrition: * Follows a low FODMAP diet, avoiding lactose and gluten due to previous bloating. Reports good adherence and finds it helps with symptoms. Ms. Jenkins reports stable bowel movements, typically 1-2 soft stools per day, without blood or urgency. She denies any abdominal pain or tenesmus. Her weight has remained stable at 65 kg over the past six months. INVESTIGATIONS * HGB: 13.2 g/dL (28 October 2024) * WBC: 7.8 x10^9/L (28 October 2024) * Neutrophils: 4.5 x10^9/L (28 October 2024) * Lymphocytes: 2.5 x10^9/L (28 October 2024) * PLT: 280 x10^9/L (28 October 2024) * Ferritin: 85 ng/mL (28 October 2024) * CRP: 2 mg/L (28 October 2024) * Creatinine: 70 µmol/L (28 October 2024) * Vit. B12: 350 pg/mL (28 October 2024) * ALT: 25 U/L (28 October 2024) * AST: 20 U/L (28 October 2024) * ALP: 80 U/L (28 October 2024) * Albumin: 42 g/L (28 October 2024) * 6-TG: Not applicable (patient on Vedolizumab) * 6-MMP: Not applicable (patient on Vedolizumab) * FCP: 110 µg/g (28 October 2024) ASSESSMENT AND PLAN * The patient is a 34-year-old female with pancolitic Ulcerative Colitis, currently in clinical and biochemical remission on Vedolizumab and Mesalazine. Problem 1. Ulcerative Colitis, pancolitis. Ms. Jenkins remains in good clinical and biochemical remission on current therapy. Her FCP remains low and inflammatory markers are within normal limits. Vedolizumab treatment to continue as per current regimen. * Faecal Calprotectin: Annually (next due October 2025) Problem 2. CRC screening. Given her diagnosis of pancolitic Ulcerative Colitis for 6 years, regular colorectal cancer surveillance is recommended. Patient informed of recommendations. * Colonoscopy: Every 2 years (next due November 2025) Problem 3. Nutritional considerations. Ms. Jenkins is managing well on a low FODMAP diet. No signs of nutritional deficiencies currently. She will continue with her current dietary approach. Problem 4. Psychological well-being. Patient reports good mental health, no anxiety or depression related to her IBD. Continues to engage with a local support group. Next consultation scheduled in 6 months for routine follow-up, to be conducted via video call, approximately 1 May 2025.