Dissonance between clinical presentation and endoscopic findings in a patient with ulcerative colitis (UC) and its impact on choosing the right treatment - a case report

Abstract

Introduction: Ulcerative colitis (UC) is a major type of inflammatory bowel disease (IBD), an im­mune-mediated chronic intestinal condition characterized by inflammation of the whole intestine from the rectum to the right colon. Patients with UC experience episodes of bloody diarrhea with mu­cous, abdominal pain, fever and weight loss. The course of UC involves phases of activity and remis­sions. The contemporary treatment involves 5-ASA agents (Mesalazine) and glucocorticoids for mod­erate to severe cases and biological therapy for inducing and sustaining long term remission. Materials and methods: We present a case of a 24-year-old man with an onset of the disease in April 2017 - appearance of blood and mucus mixed stools. He was admitted to `Eurohospital`, Varna. Fi­brocolonoscopy (FCS) with biopsy was performed and he was diagnosed with left-sided UC. The pa­tient was initially treated with Mesalazine in combination with Methylprednisolone. In November 2017 the patient was hospitalized again with 2-3 diarrheal stools per day without blood and mucus, no abdominal pain and no fever. However endoscopic findings corresponded to ulcerative pancolitis. Due to the evidence of endoscopic progression of the disease, despite the absence of complaints, he was admitted to the clinic of Gastroenterology in Saint Marina University Hospital, Varna. A number of standard tests, abdominal echo and ileocolonoscopy with biopsy were performed. Results: Ileocolonoscopy and biopsy evaluation showed severe pancolitis - endoscopic MAYO score 3 with active inflammation and postinflammatory polyps. The endoscopic results were observed while the patient was on ongoing therapy with an optimal dose of Mesalazine. Due to the young age, severe endoscopic findings and lack of improvement from the current treatment, the patient was presented to an IBD commission for starting biological treatment. Conclusion: A dissonance between clinical presentation and endoscopic findings requires an ade­quate assessment as this would help in choosing the optimal treatment for the patient.