Transcription - 20250529T 11-51.mp3

Gastroenterology doctors nice to meet you hi how are you okay how are yeah good yeah any squeeze that's always a good sign so and you feel the tongue pain at the moment you feel the tongue pain yeah I have I have had pain been I've had to catheterize quite regularly good because there was a narrowing urinary catheter no no fine you're catheterizing your pouch yeah mhmm and it didn't really do anything mhmm and so we had led to believe it could be a little bit further off mhmm they said something about wanting a pouch for a. Of time mhmm mhmm it was about a year ago you had your last pouchoscopy wasn't it november time apparently fine okay okay I haven't got 1 I'll have a look for it fine and then you had a scan mhmm did they tell you about the scan what it showed not really fine a little bit empty but so it showed a little area of thickening the same place that we saw an area of narrowing the pouches okay does that make sense yeah when you had your last I saw the pouches pouches from may and at that time it looked like there was a narrowing above the pouch yeah just before the pouch that they couldn't get the camera through and then now you're hearing obviously the pain has your has the output changed in terms of voice coming out of the back end no not really no everything the with the with the the ones from the back passage that that's have a bit of a smell to it which it doesn't normally okay but there's been no change in color I will see a bleed sometimes when I'm catheterizing mhmm but other than that not really yeah okay fine so not not much change and a number of times a day obviously said it's been less many but has it changed has the frequency changed not really no once once a day generally from that. And do you have a particular urgency do you feel anything rushed to the room can do yeah yeah okay all the time or is that something that's new for you no that that can be all the time it can be all the time yeah I haven't seen it there it doesn't matter I think a bowel trochlea is sensible just to make sure you haven't got a bowel trochlea caused by a virus that can affect you and your immunocompromised with the adalimumab you've been taking yeah and how are you doing with the adalimumab I was not taking it this week but I've been I've been taking it every week fine no trouble good fine and has the tummy pain been coming on gradually or is it more of a sudden thing it came on gradually it started last week yeah and initially they thought it could have been a water infection they treated me for that mhmm and then 1 night I came in 2 nights ago mhmm it it all really works it gone to like a scale of 11 it was like oh I'm sorry nausea within yeah was 1 right yeah 5 and what would cause the thickening then so the question is whether it's a pouchitis so whether that's caused by you know pouch is a strange thing because we take some small bowel and turn it into a: it becomes this sort of tissue type between the 2 it takes off some of the characteristics of the: and so it's able to harbour bacteria but the small bowel doesn't like bacteria very much no so the small bowel can become really irritated and get pouchitis because you've got bacteria in your small bowel right which we've turned into a: does that make sense yes no it does does so it's a dysbiosis type of thing so where your body attacks its own bowel wall because you've got bacteria there similar to crohn's disease but it happens when people wear pouches so it's possible you have a pouchitis causing a bit of your symptoms and that obviously we're seeing the inflammation just between the border between the intestine and the pouch so it could be driven by the pouch but it could also be driven by the intestine and if it's driven by activity in the crohn's disease for example we need to investigate how active it is why the adalimumab isn't working for it and if there's a problem with you and the adalimumab right so I suggest we investigate whether the adalimumab is working with a few blood tests check your levels check antibodies to adalimumab yep check your stool both stuff coming out of stoma and the back end to make sure there's not an infection that we can detect there causing things get a pouchoscopy take some samples make sure you haven't got a dysbiosis type pouchitis and then speak to my boss I suspect he'll say to get an mri of your small intestine to look for whether there's anything else causing things as well because you're having fistulating disease before so whether that swelling has led to any fistulation we won't detect that on a ct scan got you so that's what I suggest we we do to work it out I'll go and chat to my boss and make sure that he's happy it's doctor dunlop I don't know if you've met before I might have done lovely chat and we're so am I staying so I'm to the surgeons that have admitted you I'll have a chat with them about what I think is going on what they think is going on and we'll come up with a plan okay thank you I I'm I'm obviously do the bit so I can't discharge and say it's politically it's completely up to them but I would think that the findings on your ct scan warrant investigation urgently whether we do that while you're in or very urgently while you're outside and it really matters if I am in wouldn't it be prudent to try and get me up onto norfolk agreed yeah if you stay I would think that being on norfolk would be the place to be yeah yeah okay you prefer that yeah because I I generally go to either a co director ward or a for a norco I know you're in the but for quite an sau at the moment yep but yeah if if they're happy and my boss is happy we'll try and move them over if you need to stay does that sound good thank you very much we'll get a few tests to really clear out what's going on okay any questions treximet

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 small bowel decompressed. Radiologist: appears to represent ongoing or recurrent enteritis. No evidence of a collection.
Pouchoscopy May 2024: 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
? 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:
Ms Clements with complex Crohn's colitis and defunctioned ileoanal pouch presenting with 7-day history of abdominal pain, ongoing enteritis on CT unchanged from February, possible adalimumab failure requiring therapeutic drug monitoring and consideration of MRI small bowel.

Summary

Investigations

Plans