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Refined clinic letter (272 days ago 08:41)

Refined clinic letter Tue 08 July 2025 08:41

Last Modified: 272 days ago

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Content:

Diagnosis:
Evidence of micronutrient malabsorption, borderline raised faecal calprotectin and longstanding abdominal symptoms - under investigation
- Possible Crohn's Disease previously diagnosed at age 19

Other Medical Diagnoses:
• Hiatus hernia (4cm) - February 2025
• Lichen planus
• Dysmenorrhoea - Adenomyosis (endometrial ablation performed)
• Fibromyalgia
- Benign joint hypermobility syndrome (Beighton's score 9)
- Chronic fatigue
• Low vitamin B12 (2016)
• Low vitamin D
• Iron deficiency anaemia
• Previous gestational diabetes
• IBS mixed
• Depression
• Previous drug overdoses

Current Medications:
• Stexerol-D3 1000 units PO OD
• Evorel 50 patches topical twice weekly
• Progesterone micronised 100mg PO 2 tablets 2 hours before bedtime for 14 days per month
• Mounjaro KwikPen 7.5mg/0.6ml SC (private prescription) - DISCONTINUED BY PATIENT (taken for 8 weeks only)

Investigations:
• OGD (February 2025): Dysphagia, normal mucosal appearances of oesophagus, 4cm hiatus hernia, CLO test negative, histology from oesophagus showed no pathological abnormality
• Faecal calprotectin (May 2025): 152 (elevated)
• Vitamin D (January 2025): 15 (low)
• Ferritin (May 2025): 24 (low) without anaemia
• Anti-intrinsic factor antibodies (May 2025): Negative
• Anti-TTG (March 2025): Negative

Anthropometry: Weight 18 stone, height 5 foot 6 inches (patient reported).

Management Plan:
1. Pre-colonoscopy blood tests including kidney function (requested)
2. MRI small bowel
3. Colonoscopy with terminal ileal intubation, terminal ileal biopsies and colonic biopsies booked as 2-week wait due to rectal bleeding
4. Seek results from Duchy Hospital Cornwall - previous colonoscopies, histology and clinic letters
5. Clinic follow-up in 3 months

I had the pleasure of speaking to Miss Thomas in gastroenterology clinic today on behalf of Professor Lewis. The consultation was conducted over the telephone. I'm sorry to hear about the symptoms she's been experiencing for nearly as long as she can remember.

She says that from age 8 she would have to be taken out of school with recurrent episodes of abdominal pain associated with diarrhoea. At some time during her childhood she was hospitalised with these symptoms. At age 19 she saw Dr Dalton as a private patient and was diagnosed with Crohn's disease and started on prednisolone. She wasn't started on anything long-term for her Crohn's disease. She underwent a colonoscopy at this time but unfortunately I don't have any of these clinical results or letters.

In terms of her symptoms at the moment, she says that things have been particularly severe over the last 6 months where she's been feeling fatigued and under the weather. She'll experience joint pain with her bilateral knees being painful and occasionally swollen as well as her lower back pain in her buttocks. She also experiences pain and swelling in the joints of her hands. She'll notice that these symptoms are worse when her bowels are worse and "flaring".

She says that her bowels have always been an issue. She finds that eating any fibre will cause her to have diarrhoea and abdominal pain and she finds that she restricts her diet to foods which she'll be able to tolerate. She's tried a FODMAP diet and this has had no effect. Her bowels are usually loose type 5 to 6 on the Bristol stool chart and she can go over 5 times a day for over a week when her bowels are worse. She's also had several episodes of passing mucus and bright red blood associated with pain.

Regarding her family history, her brother has Crohn's disease but there's no other family history of inflammatory bowel disease. She has 2 children aged 13, has a supportive partner and works as an occupational therapist. She's soon due to start in A&E.

Reviewing her medicines I see she was prescribed Mounjaro but she only took this for 8 weeks, doesn't associate this temporally with any of her symptoms and has subsequently stopped this.

I explained that we have her symptoms which sound like they've been long-standing and significant with loose stools and pain, we have evidence of malabsorption on her blood tests with low vitamin B12, low vitamin D and low ferritin in the recent past, and we have her raised faecal calprotectin at 152. All of these point towards the potential for an inflammatory bowel disease however we should do some more tests to investigate this.

I've explained that a colonoscopy with terminal ileal intubation and biopsies from the terminal ileum as well as the remainder of the colon would be sensible as well as an MRI scan of her small bowel in order to investigate the potential for small bowel Crohn's disease.

She needs some blood tests prior to her colonoscopy to check her kidney function and I've requested these for her on our online requesting system. I'll book her an appointment in 3 months' time to discuss the results however I hope to be in contact sooner as the results come through to me.

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Refined clinic letter Tue 08 July 2025 08:41

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