Physician's Assistant

Patient Details

Refined clerking (4 days ago 14:45)

Refined clerking Thu 02 April 2026 14:45

Last Modified: 4 days ago

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Medical ST5 Miller Clerking

Presenting Complaint:
Increased stoma output

History of Presenting Complaint:
History of ulcerative colitis, previous colectomy and ileostomy formation, followed by ileoanal pouch anastomosis in 2012. He has a background of pre-pouch ileitis and pre-pouch stricture seen on pouchoscopy in December 2022, with subsequent defunctioning of the pouch with loop ileostomy in 2023. He also has a history of pouchitis and spondyloarthropathy under Rheumatology care, and is on adalimumab.

He had a pouchoscopy in February 2026 which showed a defunctioned pouch with mild diffuse pouchitis. The pouch appeared fibrotic and stenosed proximally, and the scope could not be advanced to the neo-terminal ileum as this was too uncomfortable. Biopsies showed inflammation consistent with pouchitis. He was treated with a short course of metronidazole a few weeks ago, with settling of symptoms. Repeat pouchoscopy was planned for chronic pouchitis.

He presented on 30 March with 2 to 3 days of increased stoma output and crampy abdominal pain. This was preceded by reduced stoma output, then grossly increased output of liquid bowel content. No clear precipitant was identified. C. difficile was negative. He was encouraged to use loperamide gently, take dicycloverine and drink electrolyte solutions. Stool PCR on 1 April was negative. During this admission, abdominal X-ray on 31 March showed mildly dilated small bowel centrally in the abdomen. Venous blood gas on 30 March showed pH 7.34, Hb 184 and base excess -4.3.

He remains very dehydrated biochemically, with acute kidney injury and mild inflammatory marker rise. He reports nausea and vomiting, and says that even small amounts of oral intake pass straight through. No fever, chest pain, palpitations or syncope. He is usually very active, cycling regularly, and states this is not typical for him. Stoma site itself appears healthy and pink, and he reports some chronic discomfort related to a parastomal hernia but no new local change.

Past Medical History:
• Ulcerative colitis
• Pre-pouch ileitis and pre-pouch stricture
• Pouchitis
• Spondyloarthropathy
• Cholecystectomy 2014
• Colectomy and ileostomy formation
• Ileoanal pouch anastomosis 2012
• Defunctioning loop ileostomy 2023

Drug History:
• Amitriptyline 10mg PO nocte
• Sertraline 50mg PO OD
• Adalimumab SC as per Rheumatology
• Omeprazole 20mg PO BD
• Paracetamol 1g PO QDS PRN
• Loperamide PRN

Social History:
Lives independently. Very active cyclist, rides 3 to 4 times per week, usually 80 to 120 km per ride. Works for the council. Denies smoking. Drinks alcohol occasionally. No illicit drug use.

On Examination:
Alert. Clinically dehydrated. Observations: SpO2 99% on air, BP 142/96, HR 113, RR 17.
• Abdomen: Stoma pink and healthy. Soft and non tender. Mild chronic parastomal discomfort only.
• Cardiovascular: Tachycardic. Normal heart sounds
• Respiratory: Clear chest
Reduced skin turgor, dry mucous membranes, no peripheral oedema

Investigations:
• Hb 196
• WCC 12
• Neutrophils 8.13
• Bilirubin 23
• Albumin 53
• ALT 52
• AST 54
• Creatinine 167
• eGFR 40
• Urea 6.2
• Amylase 114
• CRP 1
• Sodium normal
• Potassium normal
• C. difficile screen negative
• Fecal PCR 1 April 2026: Negative
• Abdominal X-ray 31 March 2026: Mildly dilated small bowel centrally in the abdomen
• Venous blood gas 30 March 2026: pH 7.34, Hb 184, base excess -4.3

Impression:
High-output ileostomy with marked dehydration and acute kidney injury, likely secondary to infective gastroenteritis versus inflammatory activity.  
Differential Diagnoses: Gastroenteritis; active pouchitis/inflammatory bowel disease flare; less likely mechanical/surgical cause.

Management Plan:
1. Admit for intravenous fluid replacement.
2. Strict fluid balance and input/output monitoring.
3. Add magnesium, calcium and phosphate to blood tests and replace if required.
4. Check urinary electrolytes, including urine sodium and potassium.
5. Repeat stool MC&S and C. difficile testing.
6. Check 9 am cortisol, thyroid function and coeliac serology (tTG).
7. Restrict oral intake of hypertonic fluids, tea and coffee.
8. Encourage St Mark's solution or double-strength Dioralyte; limit total oral intake to around 1.5 L/day while AKI resolves.
9. Continue loperamide and PPI.
10. Consider admission under the appropriate gastroenterology/surgical team for ongoing management and reassessment.

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Refined clerking Thu 02 April 2026 14:45

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