Ulcerative Colitis Clinical Case Review

Bharati Kochar, MD, MS, an IBD specialist at Massachusetts General Hospital and Harvard Medical School, discusses the baseline characteristics of the case.

Kochar explained that the patient, a 47-year-old woman, was initially hospitalized with fever and bloody diarrhea a week after returning from a cruise. She was diagnosed with infectious colitis and received a treatment of IV antibiotics, but her symptoms did not improve.

A colonoscopy revealed moderately active colitis, and the patient was then treated with IV steroids. She had a partial response to treatment and was discharged after 5 days with an oral steroid taper and mesalamine. She was told “that she probably has ulcerative colitis.”

Two months later, the patient experienced worsening symptoms while the steroids tapered and was told that she “more definitely has ulcerative colitis.” She was prescribed Uceris but did not respond to treatment and was re-hospitalized for severe symptoms and anemia. Upon hospitalization, she received a blood transfusion, IV steroids and infliximab (Remicade, Janssen).

Kochar discussed current AGA guidance for patients with moderate to severe UC, and how the patient had received guideline-recommended care up to that point.

When Kochar first saw the patient, she was no longer on steroids but still had bloody diarrhea. The patient underwent a flexible sigmoidoscopy that showed she had active disease, and an infliximab trough was undetectably high, which resulted in the patient being identified as a “non-responder to infliximab.” She was switched to vedolizumab (Entyvio, Takeda) and restarted on steroids.

Two months later, the patient was in complete clinical remission. However, she began to notice blood in her stool a few months later and progressively worsened until she was hospitalized again. A colonoscopy revealed that she had severe active disease. She received a surgical consultation but declined colectomy. Vedolizumab maintenance was increased to every 4 weeks after she demonstrated some response to the treatment during loading.

Kochar discussed her first visit with the patient in November 2019. At that time, she was experiencing one to three bowel movements daily with an increasing amount of blood, clots and occasional mucus, as well as tenesmus, intermittent epigastric abdominal pain and, rarely, bowel cramps.

The patient was not experiencing fecal incontinence, and her weight was stable. She was taking prednisone daily and could not be weaned off due to increasing frequency of bowel movements and increased blood in her stool.

The patient was experiencing fatigue, depression, anxiety and facial swelling while on steroids. She received treatment with vedolizumab every 4 weeks.

Kochar scoped the patient and found she had severely active chronic colitis with ulceration.