Physician's Assistant

Clinic letter Fri 30 May 2025 10:53

Last Modified: 311 days ago

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Diagnosis:
Ileal Crohn's Disease 1997
Ileocaecal resection 1997
Neoterminal ileal stricture 
- Endoscopic dilatation 2021
Bile acid malabsorption

Other Medical Diagnoses
Hypertension
B12 deficiency
Thyrotoxicosis
Bile acid malabsorption
Cholecystitis
Osteoarthritis

Medications:
Estradiol 0.06% transdermal gel (750microgram per actuation) - 3 pumps daily
Utrogestan 100mg capsules - one daily
Mometasone 0.1% cream - apply daily
Sertraline 100mg tablets - take two daily
Omeprazole 20mg gastro-resistant capsules - take two capsules (40mg) daily
Naratriptan 2.5mg tablets - take one as directed
Loperamide 2mg capsules - 2 qds prn
**Colesevelam - new medication for bile acid malabsorption**

Investigations:
MRCP 2017: Dilated CBD
DEXA scan 2012: Normal
Colonoscopy June 2021: Post IC resection changes, IC anastomosis fibrotic stricture but not inflamed, unable to intubate. CRE balloon dilatation 12-15mm, small mucosal tear at 12:00 allowing intubation. Patchy erythema in the neoterminal ileum, 1 large ulcer and several aphthous ulcers. Histology: Unremarkable fragments of ileal and colonic mucosa with no active inflammation, ulceration or granulomata
MRI Small Bowel May 2023: Single segment of acute inflammatory Crohn's disease affecting the neoterminal ileum with luminal narrowing and mild proximal dilatation, similar to previous study from 2021. Gallstones in gallbladder
CT January 2024: Oedema around first and second part of duodenum
XR Hand Both: Osteoarthrosis of bilateral PIP and DIP joints as well as bilateral thumb CMC and STT joints. No erosions or features of inflammatory arthropathy

Plan:
1. Blood tests including vitamin D, vitamin B12 and thyroid function
2. Colonoscopy (3 points) +/- dilatation of neoterminal ileal stricture
3. Consider MRI small bowel
4. Colesevelam to treat bile acid malabsorption
5. Follow-up 3 months

I had the pleasure of speaking on the telephone to Miss Parfitt on behalf of Dr Hayward in inflammatory bowel disease clinic today. I'm sorry to hear about the significant burden of symptoms which she's experiencing as well as her challenging social circumstances lately.

She describes challenges with her bowels which are "constant". She describes that eating makes her symptoms much worse and she'll rush to the toilet immediately after a meal. She's decreased her oral intake and feels like she's lost some weight because of this. She'll open her bowels with significant urgency up to 10 times per day passing yellowy loose stools.

In addition to loose stools, she describes right sided abdominal pain which is colicky and they're constantly. She describes the pain makes her quite tired and she was previously on B12 injections although these now stopped since her B12 has normalised.

In terms of her social history, she stopped smoking 2 years ago after discussions with Dr Hayward and I've congratulated her on this today. She works as a customer service representative in a shop and works long days with this. I was very sorry to hear that she's recently lost her brother to pancreatic cancer and she's now a solo carer for her elderly parents which is understandably very challenging.

In terms of extraintestinal manifestations of inflammatory bowel disease, she has stiff hands throughout the day which she finds locks. I note her recent hand x-rays demonstrating signs of osteoarthritis but without evidence of inflammatory arthropathy. She doesn't have buttock pain and she does not have any eye symptoms.

I think that her loose stools are due to bile acid malabsorption following her ileocaecal resection and I've suggested that she start some colesevelam for this which she's keen to try. She's aware that she needs to space it around her other medicines and she can increase the dose as required for her symptoms as above.

We had a discussion about how to manage her pain which is due to her neoterminal ileal stricture. We discussed options of MRI small bowel and further discussion, colonoscopy with biopsies +/- dilatation at that time or consideration of surgical options. She'd like to pursue a colonoscopy with biopsies +/- dilatation so I'll request this for her urgently as 3 points.

To investigate her fatigue, I would suggest some blood tests including vitamin D, vitamin B12 and thyroid function which I'll request and which she can have performed at Windsor House 8 till 4 weekdays.

I'll see her back in clinic in 3 months time to discuss the results of her investigations and other next steps.

Yours sincerely

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Clinic letter Fri 30 May 2025 10:53

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