- What are the major differential diagnoses?
The history suggests inflammatory bowel disease. The major
differential diagnoses are ulcerative colitis and Crohn's disease. Given the chronicity, an infectious cause is unlikely.
- What is the diagnosis here?
The gross appearance of a continuous mucosal involvment of the colon, starting from the rectum, along with microscopic ulceration of the mucosa, is most typical for ulcerative colitis.
- What is the course of this disease and what kinds of complications can develop?
The typical course is relapsing disease--flareups with intervening quiescent periods of months to years. Slightly more than half of patients have fairly mild disease that can be well-managed by medical means, particularly when the disease is limited to the rectum.
About 1/4 of patients with UC may develop a fulminant colitis. The long-term risk is colonic adenocarcinoma, which may be multifocal, and which requires consideration for performing a colectomy.
- What treatment is available?
Anti-inflammatory agents including the 5-aminosalicylic acid (ASA) compounds are used in the treatment of inflammatory bowel disease, including ulcerative colitis and Crohn's disease. Sulfasalazine is useful for treating colonic disease. up to 30% of patients experience allergic reactions or intolerable side effects including headache, anorexia, nausea, and vomiting that are attributable to the sulfapyridine moiety of this agent. Mesalamine is a newer ASA that can be used to treat disease involving the small intestine as well as the colon.
Corticosteroid therapy is useful therapy to try and produce remission of disease in cases of moderate to severe inflammatory bowel disease. Additional immunosuppressive drugs that may be used for persons whose disease becomes steroid-dependent include azathioprine and 6-mercaptopurine. Methotrexate and cyclosporine are additional alternatives for immunosuppression, but with greater potential toxicity.
Immunomodulation with probiotic therapy has been used for IBD. Prebiotics are nondigestible food ingredients that stimulate the growth and activity of probiotic bacteria already established in the colon. Probiotics are living microorganisms that can affect the host in a beneficial manner. Such organisms include Bifidobacterium, Lactobacillus, and Streptococcus species. Such organisms may alter the enteric microflora that modulates cytokine release patterns by gut-associated lymphoid tissue.
- What psychosocial issues can you identify for this illness?
At one time, inflammatory bowel diseases were considered by some as 'psychosomatic' diseases and patients were labelled as 'high-strung' and annoying 'whiners' so that their concerns were often minimized by professionals. Prior to diagnosis, patients may not understand why they have the problems they do.
However, this disease should now not go undiagnosed. Explain to the patients why they have the symptoms and signs they do. That still does not alleviate unpleasant problems at unpredictable times, such as emergently seeking a rest room, or having the 'fasten seat belt' sign on during a turbulent airplane flight, or having symptoms occur in the middle of a social gathering, such as at a mosque, temple, or church. This can lead to social withdrawl and depression very easily.
