History
A 32-year-old gentleman presented with bloody diarrhoea 9 months ago. Colonoscopy revealed pancolitis and he was treated with corticosteroids. Steroid dosage was gradually tailed down and he was maintained on mesalazine treatment. He was a smoker and quitted smoking 6 months after his initial presentation due to the birth of his daughter. He presents again with bloody diarrhoea up to 10 times per day. He has a fever and mild abdominal pain.
•Temperature 38.3°C, fever, pulse 130 bpm, BP 100/80mmHg, SaO2 99% on RA.
•Tired-looking, hydration on the dry side.
•Examination of the hands reveals no clubbing and normal-appearing palmar creases.
•Head and neck examination is unremarkable.
•Cardiovascular: HS dual, no murmur.
•His chest is clear on auscultation.
•Abdominal examination reveals a soft abdomen, with no peritoneal signs.
•No signs of oedema.
Investigations
•CBC for leukocytosis and thrombocythemia.
•Liver and renal function tests for electrolyte disturbance and renal impairment.
•Inflammatory markers: ESR, CRP.
•Blood for culture to rule out septicaemia in view of high fever.
Blood tests reveal thrombocytosis and raised inflammatory markers.
What is your differential diagnosis?
The differential diagnosis includes a flare up of ulcerative colitis and infectious colitis.
What other tests would you order?
•Stool for bacterial culture.
•Stool for norovirus.
•Stool for Clostridium difficile toxin A and B.
•A sigmoidoscopy may be considered (AVOID full colonoscopy as there is a high risk of perforation).
•Abdominal X-ray to rule out toxic megacolon.
How would you assess the severity of the flare?
The severity of an acute ulcerative colitis flare can be assessed by the Truelove and Witts’ criteria, as outlined below in Table 4.1 1.
Table 4.1. The Truelove and Witts’ criteria. | |||
Mild | Moderate | Severe | |
