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Clinic letter (311 days ago 09:27)

Clinic letter Fri 30 May 2025 09:27

Last Modified: 291 days ago

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Content:

Diagnosis:
Crohn's Disease
2025: Continued activity +/- element of bile acid malabsorption.

Medications:
Loperamide PRN only

Investigations:
- Colonoscopy July 2021: Narrowed neoterminal anastomosis with mild nonspecific inflammation in the IC valve
- MRI small bowel September 2021: 2 fibrotic strictures of 3.5 and 2.5 cm length in the neoterminal proximal small bowel, not dilated
- MRI small bowel with contrast September 2023: 2 fibrotic strictures in the neoterminal ileum 2.5 centimetres each, anastomotic stricture causing pre-stenotic dilatation of the small bowel
- Laparotomy and adhesiolysis for Crohn's January 2024. Operative findings: IC resection and Kano S reanastomosis, findings of dense adhesions, ileocolic knot of small bowel with adhesions, short stricture at the anastomosis within the knot, no other strictures, excellent length of small bowel remaining
- Colonoscopy January 2025: Ulceration of the anastomosis and some larger based ulcerations of the neoterminal ileum, Rutgeerts I2b, intervening mucosa normal, unable to deeply intubate neo-TI due to angulation, single ulcer seen opposite tattooed mesenteric border 5 cm distal to anastomosis, no other evidence of Crohn's seen.
- Histology: Neoterminal ileal biopsies - actively inflamed intestinal mucosa and ulcer slough, no evidence of dysplasia or invasive neoplasia, CMV negative. Anastomosis biopsies - small intestinal mucosa showing active chronic inflammation, no evidence of dysplasia or neoplasia, no viral inclusions or CMV. Serial colonic biopsies x6 - mild crypt architectural distortion but no evidence of significant inflammation, dysplasia or invasive neoplasia, no granulomas or viral organisms
- Bloods Jan 25: High platelets, neutrophilia, low transferrin saturation without anaemia.

Plan:
1. Course of steroids following MRI small bowel
2. MRI small bowel
3. Discussion at IBD MDT
4. Signposting to inflammatory bowel disease nurses
5. Blood tests including inflammatory markers, nutritional assessment and pre-biologic screening
6. Dietetic review
7. Follow up in 6 weeks

Dear GP,

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

Miss Harvey has had terminal ileal Crohn's disease since the nineties and has had multiple operative managements for this including most recently in January 2024 when she underwent further ileocaecal resection, adhesiolysis and reanastomosis.

Unfortunately, since then she's had more watery loose stools with significant faecal urgency including overnight. Unfortunately, she's even had some accidents with this watery stool. She will get up overnight to open her bowels most nights of the week and during the day might open her bowels 10 to 15 times passing loose watery stools with significant urgency. She started herself on loperamide to try and manage this and it's made a slight improvement but not transformative.

In terms of her diet, she's been trying to go back to her normal diet however has been decreasing her fruit and veg fibre intake in order to try and slow down her bowel movements.

In terms of her family history, her son has been diagnosed with Crohn's disease.

We discussed today that her recent colonoscopy in January demonstrated ulceration of her anastomosis and in the neoterminal ileum and biopsies from here have demonstrated activity in her Crohn's disease.

She's never been on any treatment in terms of medical treatment for her Crohn's disease and we discussed this briefly today. She struggled with her heparin injections following discharge from her IC resection so she's reluctant to explore injection medicines but would consider tablets or infusions.

She works in a restaurant kitchen and obviously opening her bowels this frequently is quite challenging for her. She decides not to eat in order to limit her bowel motions.

We discussed that it may be that activity in her disease is causing things. It seems most likely and so it'll be sensible to investigate this further with an MRI of her small bowel as well as start some treatment in the form of steroids following the MRI scan. I'll discuss her case at the inflammatory bowel disease MDT and we can establish what the optimal treatment would be for her. I've also asked her to see the dietitians and look forward to following her up again in 6 weeks' time with some results.

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Clinic letter Fri 30 May 2025 09:27

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