Kilo068791 robert iles I l e s clinic letter 58 year old man diagnosis crohn's disease diagnosed 19 '88 most recent colonoscopy march 2022 generalized mild crohn's proctocolitis histology confirmed appearance of those of moderately reactive chronic inflammatory disease in a previously known case of crohn's disease with no evidence of dysplasia or malignancy most recent fecal calprotectin february 2022 01/1965 other medical ankylosing spondylitis on adalimumab open brackets humira close brackets injections 40 mg subcutaneously every 2 weeks current medication is octaser 2.4 g once per day adalimumab 40 mg subcutaneously every 2 weeks laxia as required lactulose as required hi is that mister ross I guess it was hi I'm rob miller I'm 1 of the gastroenterology registrars here at dareford I'm calling you for clinic today I hope I've caught you at a reasonable time no no you had they do this weird thing with the clinics where they front load all the patients so they put all of the slots really close together so yeah I don't know why they do it but anyway I'm sorry that you've been waiting around no exactly so that's good exactly yeah so I'm 1 of the gastroenterology registrars I see that you had previously had diagnosed crohn's disease managed in bedfordshire but welcome down to the southwest are you you happy you moved good yeah you brought the weather with you I was gonna say which is good okay good yeah fine good I'm glad I was about to you know but no we're okay now good it's good to get it off your chest for sure so you're from you grew up around here in bumitracy lovely fine nice and you're returning down here too to be close to family or for work or what's your thing mhmm yeah okay fine fair enough but I'm sure they'll love being down here as well fine yeah that's a worry and what do you do for a living you don't mind me asking mhmm okay lovely yeah fine great and you and obviously you have crohn's disease do have any other health problems mhmm yep yeah hla b27 yep okay that's good and you take the humira for the ankylosing spondylitis of course we use it for crohn's all the time so it's a great medicine for both yeah okay great great and how have you found your bowels been over the last sort of few months yeah feel like you've got something left behind okay yeah and this is tummy pain lower tummy pain upper tummy pain middle yeah does it kind of become very does it peak and then drop off again and then peak and drop off again or is it very constant type pain yeah fine it's a colicky type pain yeah goodness fine and you had that in the last few months or is that something that affects you regularly okay mhmm mhmm okay and then in terms of the feeling that you can't get everything everything out the tenesmus that you is what we call it that feeling and do you have have has that changed recently or has that been a long standing thing okay that's good okay because we always worry about that whether there might be a polyp close to the back passage that's causing that but you had a colonoscopy in that time didn't you 1 in 3 years ago 2022 which would have seen if there was anything sinister or worrying there but you're looking at the results that we got through from ben fisher you had a bit of activity at that time in your in your: a bit of disease activity particularly just near the back passage and that can cause the kind of symptoms you're you're describing I think you would be due a surveillance colonoscopy given the findings with the results that I've got because you would think you'd fall into the 3 year category so you would be due a colonoscopy to if you'd like I can organise that for you or if you want to give it a bit of time that's also absolutely fine well we're very lucky lucky you've come to the best place in the world and we're very lucky with our waiting list that we'll get you through quite quickly if I book you a colonoscopy it'll happen in the next few weeks yeah exactly but then I'm gonna have it sooner yeah of course well well good I think that's good so why why don't I book it for you routinely it'll happen sometime 4 to 6 weeks time may give you a bit of time for the elation to fade away and the dread to set in that sounds perfect oh fine no that's fine fine and then in terms of the symptoms of the pain that you get I don't know is anyone gonna talk to you about narrowings that you can get in the small bowel because of crohn's disease or strictures etcetera no it's fine yeah the tenesmus the feeling that something's left behind yeah of course well what given we're taking over your care from the team in bedford I I wonder whether it may be sensible to do a kind of mot restage your disease do an mri of your small intestine make sure you haven't got any narrowings there which are causing your symptoms and it'll also show us how active everything is in your small bowel we'll get a colonoscopy we'll look at activity in your large bowel and then we can put those 2 together and see how well your adalimumab is controlling things whether you've got an arrow in there and talk about what's causing your symptoms I think you're right that your symptoms would be much more regular and much more severe if you had a significant stricture but it's worth considering whether there's inflammation there as a cause for those symptoms which you know might be amenable to switching to a different treatment like that yeah sounds good so I'll get you an mri of your small bowel we'll do the colonoscopy who's gonna prescribe your humira have you spoken to a rheumatologist down here good yeah fine great so that's all taken over the medicines delivery company are still delivering to you so you're still getting that fantastic great brilliant so that's cool your you had some blood tests relatively recently which your kidney function looks fine for the bowel prep things like that so there's nothing to worry about there so I'll request those few bits and bobs I'll call you with the results when they I'll send you a letter depending on what the results show and then we can see you again in clinic in in probably about a year's time I would think given we've sort of crossed all the t's and dot's all the i's today but if things change in the meantime we've got inflammatory bowel disease nurses here and I'll put the helpline number on the letter that I sent you so you'll be able to get in contact with them if there's any questions or queries or you're flaring or there's a problem with the medicine supply that we can try and help with and you can always get in contact with the secretaries and get in contact with me as well I can imagine yeah yeah exactly yeah yeah but by that time when you're rolling around in bed in pain it's probably too late isn't it so so we'll just have a look now shall we and just we'll get an mri of your bowel and we'll see what it looks like that should happen in the next few weeks as well is that okay anything I've forgotten any questions or queries yes have you not okay fine tell me about that you I I see oh well fine it's an open scanner yeah yeah no no you know it's entirely reasonable I think we'll we'll if you're not keen to try we don't have an open scanner here we have a normal standard mri scanner which obviously if you're claustrophobic may not not be the best it is a very good test to look at all of the small bowel however we will get a reasonable view of activity in the small bowel like your colonoscopy because we'll go into the last part of the small bowel which is the most common place that creates these effects so we get a good idea but we won't get the best idea what we could do is talk about it later and you could have a think about it we could see what the colonoscopy looks like see if there's activity in your small bowel if there is that would give us further weight to think about whether we wanna do it and in the meantime we can shelf the mri scan if prefer that you may meet me at the time of the colonoscopy or it may be 1 of my colleagues but I'll call you with the results or send you a letter depending on depending on what it shows really if there's anything to talk about then I'll usually give you a call but it'll be 1 of those random sort of 04:00 in the afternoon calls which you obviously might be busy yeah get it done now okay fair enough yeah I think yeah no no that's fine yeah because we feel like we've got options haven't we I think let's let's see how the how it goes I'll explore whether we have access to an open scanner around here with some of my consultants and see if there's anything they've used in last and I'll get in contact with you we can talk when the colonoscopy is back I'll have some info about the open scanner we can take it from there instead of rushing up to them I know I'm pretty sure it's head first but I think your head does poke out the other end slightly but only slightly I think you have to endure going through the tunnel head first yeah yeah no it's okay no it's a pleasure yes yeah exactly so it'll be good I'll we'll see some results and and we'll keep looking after you and if there's any trouble or worries or you have questions just get in contact with us and we'll get in touch with you no worries at all have a nice rest of your day enjoy the sun thanks bye so plan number 1 colonoscopies for surveillance number 2 explore option of local open mri scanner and get back to patient number 3 call with results number 4 ibd follow-up in a year's time number 5 if flaring contact ibd nurses for advice dhcp had the pleasure of speaking on the telephone to mister iles who's been previously looked after in bedfordshire for his diagnosis of crohn's disease which was diagnosed in 1988 full stop he's moved down to the southwest or back to the southwest I should say we're very happy to be taking over his care moving forward full stop <\n\n> In terms of his life more generally he works as a business consultant for food brands he has 3 children and and a wife who he lives with at home full stop <\n\n> He says his bowels are quote pretty good quote passing form stool once or twice per day full stop however, he does describe occasional feeling of tenesmus over the last 4 years which I explained may well be due to the small amount of proctocolitis that was identified at his previous colonoscopy full stop <\n\n> Additionally, he has had a couple of years of episodes of pain at night which he describes as colicky mid to lower abdominal pain which can be very severe full stop most recently was 5 months ago full stop he attributes this to consumption of spicy food however he rightly raises the possibility of a stricture causing these symptoms full stop <\n\n> We discussed today that he's due colonoscopy surveillance given he had some activity at the time of his previous colonoscopy so I'll arrange this for him full stop we discussed the option of an mri of his small bowel to investigate the potential for a stricture however he's quite claustrophobic and so would like to avoid this if he can full stop he's previously had good success in using open mri scanners in birmingham I'll get in contact with my local team to see whether there's anything we can offer similar to this locally full stop <\n\n> He's been in contact with a rheumatologist locally who's taken over the prescription of his adalimumab open brackets humira close brackets for which he uses for ankylosing spondylitis but also has a positive effect for his crohn's disease full stop <\n\n> We'll we'll arrange to see him back in clinic in a year's time and I look forward to writing or calling with the results of the colonoscopy and my discussions around mri open mri scanners in our local area we'll see him back in clinic in a year's time but he's more than welcome to get in contact with me or the secretaries if he has any concerns queries or is flaring in the meantime yours sincerely