Physician's Assistant

Clinic letter Fri 30 May 2025 08:38

Last Modified: 283 days ago

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Diagnosis:
Bile acid malabsorption secondary to ileocaecal resection
Focal colonic thickening on CT for further investigation

Other Medical Diagnoses
- Left robotic upper trisegmentectomy and lymph node dissection September 2022 for lung cancerasas
- COPD
- Appendicectomy
- Hernia repair
- Terminal ileitis (December 2022) requiring operative management with reduction of parastomal hernia, division of adhesions, ileocaecal resection, resection of Meckel's diverticulum and right hemicolectomy

Medications:
- Colesevelam - increase to effect

Investigations:
- Colonoscopy November 23: Normal mucosa in the colon to the neo terminal ileum, multiple scattered aphthous ulcers, 1 flat elevated polyp in the sigmoid (removed)
- Histology from neo terminal ileum: Preserved villous architecture, 1 fragment demonstrating moderate active chronic inflammatory infiltrate within the lamina propria but without granulomas, dysplasia or malignancy
- Sigmoid polyp (10 x 10 x 5 mm): Simple benign hyperplastic polyp
- Colonoscopy August 22: Rectal polyp resected. 5mm sigmoid polyp not resected. Terminal ileum ulcerations and oedematous mucosa. 
- CT Thorax March 25: Focal colonic thickening the splenic flexure, may be due to peristalsis however similar findings seen 1 year ago raises the possibility of focal colonic lesion.

Plan:
1. Increase colesevelam to effect
2. Blood tests including testing for fat soluble vitamins
3. Two week wait colonoscopy
4. Patient initiated follow-up for 12 months

Dear GP,

I had the pleasure of speaking on the telephone to Mr Jones today on behalf of Dr Hayward in gastroenterology clinic.

He was initially referred to our service following terminal ileitis and loose stools. His loose stools have been attributed to ibuprofen use and his terminal ileitis to this as well, so his loose stools and terminal ileitis were secondary to ibuprofen. After a lung resection he developed an ileus and required operative management which involved an ileocaecal resection and a resection of a Meckel's diverticulum. Reassuringly, none of the histology from his colonoscopies nor his Meckel's resections have demonstrated any evidence of inflammatory bowel disease and certainly not Crohn's disease.

When he last saw Dr Suarez in 2023 he started some colesevelam which he found very beneficial and has greatly improved his symptoms. He describes his bowels currently as a little loose still and he'll open his bowels 2 to 3 times per day, mostly in the morning. Reassuringly, he doesn't have significant urgency and doesn't rush to the toilet immediately after eating. He's taking the colesevelam twice a day. He works as a bus driver and still finds that he's able to undertake his shift the majority of the time without needing to open his bowels.

We discussed today that we don't think he has inflammatory bowel disease and that his symptoms are attributed to a combination of ibuprofen use and bile acid malabsorption following his ileocaecal resection.

I've advised him that he can increase the dose of his colesevelam as above to improve his symptoms as long as he spaces it alongside his other medicines. Lack of terminal ileum can result in decreased absorption of fat soluble vitamins and so I'll send him out some blood tests including vitamin D in order to ensure that this is replete.

I've not arranged to see him again in clinic but have enrolled him into patient initiated follow-up. If he has any queries or concerns or his symptoms worsen despite the colesevelam, I'm more than welcome to see us in clinic again.

On reviewing his investigations, I note that a recent CT thorax performed for follow up following his lung resection has demonstrated signs of splenic flexure colonic thickening which have been persisting for 1 year.  The radiologist has advised direct visualisation and I agree this is sensible so I will request him a 2 week wait colonoscopy.

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Clinic letter Fri 30 May 2025 08:38

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