Consult Colonoscopy IBD patient

DATE: 11/01/2024 PROCEDURE: "Colonoscopy" PRE-PROCEDURE DIAGNOSIS: • Crohn's Disease, active • Abdominal pain • Diarrhoea POST-PROCEDURE DIAGNOSIS: "[]" IBD PROFILE Diagnosis • Crohn's Disease, ileocolonic, L3, B1, diagnosed in July 2018 by Dr. Eleanor Vance at St. Jude's Hospital. Summary of course • In July 2018, patient was diagnosed with ileocolonic Crohn's Disease (L3, B1) by Dr. Eleanor Vance after presenting with chronic abdominal pain and bloody diarrhoea. Initial treatment involved oral corticosteroids and mesalazine. • In September 2018, patient was started on Azathioprine 50mg daily due to ongoing symptoms and corticosteroid dependence. Fecal calprotectin (FCP) was 850 µg/g. • In January 2019, patient experienced a flare with increased abdominal pain and diarrhoea. Treatment was escalated to infliximab induction therapy. Infliximab trough level was 5.5 µg/mL. • In April 2019, symptoms improved significantly with infliximab maintenance. FCP was 120 µg/g. • In October 2020, patient developed arthralgia and fatigue. Infliximab dose was increased. Infliximab trough level was 4.2 µg/mL. • In March 2021, patient reported good control of GI symptoms. FCP was 80 µg/g. • In December 2022, patient had a mild flare, managed with a short course of oral prednisolone. • In June 2023, patient reported well-being with no active symptoms. Infliximab trough level was 6.8 µg/mL. FCP was 65 µg/g. • In October 2024, patient presented with increased frequency of bowel movements, abdominal cramping, and mild weight loss, prompting current colonoscopy consult. Current Treatments: • Infliximab 5mg/kg IV every 8 weeks • Azathioprine 100mg daily • Folic Acid 5mg weekly Preventative • Vaccinations: Influenza vaccine (Oct 2024), Pneumococcal vaccine (Jan 2023), Tetanus/Diphtheria/Pertussis (Jan 2020), Hepatitis B series completed (2018). • Infection screening: HBV negative (Oct 2024), HCV negative (Oct 2024), TB Quantiferon Gold negative (Oct 2024), CXR normal (Oct 2024). • Nutrition: Low FODMAP diet, avoiding dairy due to lactose intolerance. Currently experiencing occasional abdominal cramping and 3-4 soft bowel movements per day, sometimes with urgency. No significant pain requiring analgesia. Patient reports mild weight loss of 2kg over the past 3 months. FAMILY HISTORY • Mother: Type 2 Diabetes • Father: Hypertension, no history of polyps • Maternal Aunt: Ulcerative Colitis PAST HISTORY • Childhood asthma, resolved • Appendectomy (2010) • Iron deficiency anaemia, managed with oral iron supplementation OTHER MEDICATIONS • Multivitamin daily • Calcium + Vitamin D supplement daily ALLERGIES • Penicillin (hives) SOCIAL HISTORY Patient is a 32-year-old married female with two children. She works full-time as a graphic designer. She denies smoking, reports occasional social alcohol consumption (1-2 units per week), and denies marijuana use. PHYSICAL EXAM: "The abdomen was soft, non-tender, with no hepatosplenomegaly or masses. Cardiovascular, respiratory, lymph node, and dermatological examinations were normal." INVESTIGATIONS: • Fecal calprotectin (Oct 2024): 450 µg/g (elevated) • CRP (Oct 2024): 15 mg/L (elevated) • ESR (Oct 2024): 30 mm/hr (elevated) • Infliximab trough level (Oct 2024): 3.1 µg/mL (subtherapeutic) • Haemoglobin (Oct 2024): 10.5 g/dL (mildly anaemic) CONSENT: "Informed consent was obtained after having reviewed the rationale and alternatives for the procedure as well as its risks, which include but are not limited to: sedation-related adverse effects, bleeding, missed lesions, perforation potentially requiring surgical intervention, and infection." SEDATION: "Intravenous conscious sedation consisting of midazolam [] mg and fentanyl [] mcg. ;procsedation" PROCEDURE: "After a time out, digital rectal examination was performed. An adult colonoscope was inserted into the rectum and advanced with the use of water insufflation and positional changes to the level of the cecal pole. Normal cecal pole landmarks were identified with clear visualization of the ileocecal valve and appendiceal orifice. Photographs were obtained. The colonoscope was carefully withdrawn. Satisfactory mucosal views were achieved with the use of dynamic positional changes, irrigation and suctioning of all pools of residue, mucus and fluid, segment reassessment, and retroflexion. The colonoscope was removed and the patient was returned to the recovery room having tolerated the procedure well." QUALITY INDICATORS: "1. Bowel prep: [] 2. Extent of examination: [] 3. Withdrawal time: [] minutes 4. Technical difficulties: [None] 5. Unplanned events: [None]" ASSESSMENT AND PLAN: Assessment: 32-year-old female with known ileocolonic Crohn's disease presenting with a suspected flare, evidenced by increased bowel movements, abdominal pain, mild weight loss, elevated inflammatory markers (CRP, ESR, FCP), and subtherapeutic infliximab levels. Current colonoscopy performed to assess mucosal inflammation and disease activity. Plan: 1. Increase infliximab dose and/or decrease interval, pending colonoscopy findings. Target trough level above 5 µg/mL. 2. Consider adding immunomodulator or switching to a different biologic if mucosal healing is not achieved. 3. Follow-up: Schedule a follow-up appointment in 2 weeks to discuss colonoscopy results and adjust treatment plan accordingly. 4. Dietitian referral for continued nutritional support and dietary modifications. 5. Monitor inflammatory markers (CRP, FCP) and infliximab trough levels regularly. 6. Continue current iron supplementation for anaemia.