Transcription - 20250529T 11-38.mp3

Tracy marie clements 8 9 9 2 2 4 investigations crp less than 1 using his normal lfts normal fills 9.5 with white cells 13.1 hemoglobin a 34 ct abdomen and pelvis with contrast performed with symptoms of diffuse abdominal pain for 7 days thick walled section of proximal to the pouch measuring approximately 10 centimeters in the midsection underlying the anterior abdominal wall the same area that demonstrates inflammation in the february study and appearances are broadly unchanged distal ileum to this is the known stricture and on today's study this area is collapsed and therefore not readily accessible a small amount of fluid is present between the within the ileoanal pouch indicating the stricture segment is patent the more proximal ileum is fluid filled and of a broadly similar caliber to the previous studies right iliac fossa ileostomy is unremarkable with no evidence of obstruction or stricture proximal wall bound decompressed radiologist appears to represent ongoing or recurrent enteritis no evidence of a collection suggest infliximab or imraldi adalimumab sorry not infliximab adalimumab therapeutic drug monitoring with levels and antibodies number 2 check cmv serum titers number 3 stool culture for mcns number 4 I'll discuss with doctor dunlop

Investigations:
CRP <1 (normal)
U&Es normal
LFTs normal
Eosinophils 9.5
White cell count 13.1
Haemoglobin 134
CT abdomen and pelvis with contrast: Performed for symptoms of diffuse abdominal pain for 7 days. Thick-walled section proximal to the pouch measuring approximately 10 centimetres underlying the anterior abdominal wall. The same area that demonstrated inflammation in the February study and appearances are broadly unchanged. Distal ileum to this is the known stricture and on today's study this area is collapsed and therefore not readily accessible. A small amount of fluid is present within the ileoanal pouch indicating the stricture segment is patent. The more proximal ileum is fluid-filled and of a broadly similar calibre to the previous studies. Right iliac fossa ileostomy is unremarkable with no evidence of obstruction or stricture. Proximal wall bound decompressed. Radiologist appears to represent ongoing or recurrent enteritis. No evidence of a collection.
Pouchoscopy May 24: afferent ileal anastomosis appears narrowed and would not admit the scope. Mild ulceration-similar to last Pouchoscopy in 2021

Thank you for asking me to review Ms Clements, who presented with a 7-day history of diffuse abdominal pain.

Complex history of Crohn's Colitis since 1995 with recurrent severe proctitis. 
Anaphylactic reaction to infliximab on the second dose in 2014. 
Defunctioned ileoanal pouch and ileostomy from 2018 due to recurrent pouchitis. 
Adalimumab (Imraldi 40mg) once weekly since 2019. 
Right buttock abscess in November 2022 requiring incision and drainage, with recurrence in August 2023 again requiring incision and drainage.

Her recent CT shows ongoing inflammation in the same area as the February study with no significant change. There is a known stricture in the distal ileum which appears collapsed on today's imaging. The ileostomy appears unremarkable with no obstruction.

Her inflammatory markers are reassuringly low with a CRP <1, though she does have a mildly elevated white cell count of 13.1 and eosinophilia of 9.5.

Impression:
Ongoing enteritis - Crohn's vs infective
- investigate adalimumab treatment failure

Suggest:
1. Adalimumab therapeutic drug monitoring with levels and antibodies
2. Check CMV serum titres
3. Stool culture for MC&S please
4. I will discuss with Dr Dunlop re further imaging ? MRI Small Bowel

Summary

Investigations

Plans