This document describes a case of a patient with refractory left-sided ulcerative colitis. The patient presented with a history of loose stools mixed with blood and was diagnosed with ulcerative colitis 1.5 years ago. Colonoscopy and biopsy reports confirmed left-sided ulcerative colitis. The patient was treated with corticosteroids, mesalamine, and antibiotics, which resulted in decreased bleeding and normalization of stool consistency by day 6. The treatment plan aims to induce remission and maintain quality of life through medication, monitoring, and lifestyle modifications.

1. ULCERATIVE COLITISREFRACTORY
{LEFT SIDED COLITIS}
DONEY JOSEPH
PHARMD INTERN

2. Ulcerative colitis is a chronic inflammation of the large intestine
(colon). The colon is the part of the digestive system where water
is removed from undigested material, and the remaining waste
material is stored

3. Left-sided colitis: As the name
suggests, inflammation extends from
the rectum up through the sigmoid and
descending colon, which are located in
the upper left part of the abdomen.
Signs and symptoms include bloody
diarrhoea, abdominal cramping and pain
on the left side

4. REASON FOR ADMISSION
History of loose stools since 1 week{8 times daily}, associated
with blood mixed stools
Patient is also a k/c/o of ulcerative colitis since 1.5 years{drug
induced}
No history of fever , anorexia , weight loss, vomiting, etc..
NSAID induced
No pallor/icterus

5. PREVIOUS REPORTS..
10/01/2013 : histopathology report of colon was Active
ulcerative colitis
On 1/09/2013: colonoscopy report was: ulcerative colitis left
sided
On 17/10/2013: biopsy report was : acute ulcerative colitis

6. DAY 1..
Bp:110/70 mmhg
pulse: 78bpm
CVS
RS
NAD
CNS
Adv:HB,ESR,PCV,TC,DC,RBS,PBS,SE,TSH,LFT,ECG,AntiHCV,Elisa
Plan for colonoscopy tomorrow

7. LAB REPORTS
Hematology
Hb- 9.3% ( 13-16g%)
Biochemistry
RBS- 77 mg/dl
WBC- 8200 (4000-11,000) cells/mm3
ElectrolytesSodium- 145 mmol/l
Potassium- 4.2mmol/l
Chloride- 99 mmol/l
DLC- N- 57%
B- 01%
M- 01%
E- 04%
L-37%
ESR- 50 mm/hr (0-10mm/hr)
Anti-HCV,ELISA- negative
PBS: Microcytic hypochromic anemia
Thyroid profile
T3: 1.28 (0.60- 1.81ng/ml)
T4: 7.7 ( 4.5- 10.9 mcg/ml)
TSH:0.69 (0.35- 5.5 IU/ML)

8. LFT:( mg/dl)
AST: 15 (0-40)
stool microscopy:
No inflammatory cells and parasite
ALT: 12 (0-40)
ova or cyst are not seen.
ALP: 204 (40-376)
ECG: WNL
Albumin: 3.4 ( 3.5-5)

9. MEDICATIONS..
Inj hydrocortisone iv q6h 100 mg
PROCTOCLYSIS-ENEMA
1-0-1
Capsule VSL3
1-0-0
Tablet mesalamine po 1.2mg 2-0-0
Tablet pantoprazole po 40mg 1-0-0
Tablet eldicet{Pinaverium} po 50 mg 1-0-1

10. DAY 2..
Bp:110/70 mmhg
CVS
RS
NAD
CNS
pulse: 80bpm
Patient passed stools mixed with blood, patient advised for
PROCTOCLYSIS-ENEMA for colonoscopy
Colonoscopy report: IBD- proctosigmoiditis

11. Ulcerative proctitis. In this form of ulcerative colitis,
inflammation is confined to the area closest to the anus
(rectum), and for some people, rectal bleeding may be the
only sign of the disease
Proctosigmoiditis. This form involves the rectum and
the lower end of the colon, known as the sigmoid colon..

12. DAY 3.
BP: 120/80mmhg
pulse:
78bpm
CVS
RS
NAD
CNS
P/A-soft , patient complains of blood mixed stools
ADV: CST

13. DAY 4.
Bp:120/80bpm
pulse: 80bpm
CVS
RS
NAD
CNS
Freequency of loose stools decreased, decreased amount of blood in the
stool
ADV:to stop Inj hydrocortisone
Started tablet Methylprednisolone 16 mg po 2-0-0
Tablet calcium carbonate
500 mg po 0-1-0

14. DAY 5..
Bp: 110/70mmhg
pulse: 78bpm
CVS
RS
NAD
CNS
P/A-soft, patient complaints of semi solid stools not associated
with blood{ 3-4} episodes
ADV:CST

15. DAY 6..
Bp: 120/80 mmhg
pulse: 80bpm
CVS
RS
NAD
CNS
Patient did not have any complaints of loose stools, no history of
blood in the stool
ADV: CST

16. PHARMACEUTICAL CARE PLAN

17. Subjective evidence
• Loose stools
associated with
blood
• k/c/o ulcerative
colitis
Objective evidence
• Colonoscopy report
• Histopathology
report
• Biopsy report

18. FINAL DIAGNOSIS
Based on subjective and objective evidence
ulcerative colitis with refractory – left sided
colitis

19. GOALS OF TREATMENT
Terminate the acute attack and induce clinical remission.
Maintain remission during quiescent symptom-free periods.
Control symptoms during symptomatic periods.
Prevent or control complications.
Avoid surgery, if possible.
Use the most cost-effective drug treatment.
Maintain or improve quality of life.

20. TREATMENT OPTIONS
Aminosalicylates:sulfasalazine {3-4g/day}
Mesalamine
Corticosteriods: hydrocortisone{300mg/day}, methyl
prednisolone{20-60mg/day}
Immunomodulators: Azathioprine{2-3mg/kg/day} ,6mercaptopurine{1-1.5mg/kg} , Methotrexate{25mg/week},
Antibiotics:Metronidazole

21. WHEN SURGERY INDICATED????
1. Fails to respond to medical management acutely or
chronically,
2. Develops uncontrollable drug-related complications,
3. Experiences impaired quality of life from the disease or its
drug therapy,
4. Develops carcinoma of the rectum or colon.

22. SURGICAL METHODS..
Total proctocolectomy with ileostomy :Total proctocolectomy
with ileostomy is surgery to remove all of the colon (large
intestine) and rectum. Then a hole in abdomen, called a stoma,
is made. Waste will move from the small intestine, out the
stoma, and into a plastic ostomy bag.

23. ILEAL POUCH ANAL ANASTOMOSIS
The most common procedure for ulcerative colitis is pelvic
pouch or ileal pouch anal anastomosis (IPAA). colon and
rectum will be removed. A new rectum, called a J-pouch, will
be fashioned out of small intestine. This type of surgery
allows to have bowel movements .

24. CONTINENT ILEOSTOMY:
The least common surgery for UC is continent ileostomy. Also
called the Kock pouch, it's a very technical surgery.. During
the procedure colon and rectum are removed. Small
intestine is used to create a holding place (reservoir) for
waste that will be drained from a valve in abdomen

25. GOALS ACHIEVED
No more episodes of loose stools and bloody
stools by day 6

26. PROBLEMS IDENTIFIED
Untreated anemia

27. MONITORING PARAMETERS
Weight
CBC
Colonoscopy
Glucose levels
Electrolytes level

28. PATIENT COUNSELLING
About disease:
signs and symptoms
risk factors
complications
About medications:
medication adherence
Possible side effects

29. LIFE STYLE MODIFICATIONS:
A well-balanced, nutritious diet can help maintain health and a
normal body weight.
Pain medications that contain nonsteroidal antiinflammatory drugs
(NSAIDS), such as ibuprofen and naproxen ,are not usually
recommended