Ulcerative Colitis Clinical Case Review

Michael Dolinger, MD,an assistant professor of pediatric gastroenterology at the Icahn School of Medicine and Mount Sinai Kravis Children's Hospital, discusses the baseline characteristics of the case:

Editor’s note: The following is an automatically generated transcript of the above video.

“I am going to start with a case. We have a 19-year-old female with a history of left-sided ulcerative colitis that was diagnosed at age 15 years. She was stable on mesalamine for 3 years. She had Mayo 2 colitis. She responded initially to mesalamine and did very well, and she didn't have an official treat to target colonoscopy within 1 year as she was in clinical remission. But prior to starting college, we performed a colonoscopy in her, and it demonstrated complete endoscopic remission with absence of erythema or ulcers, a Mayo endoscopic score of 0 throughout the entire colon. And in histology, there was mild chronic activity in the sigmoid colon and the rest was completely healed.

So, the story for her really begins when she returns from college. She returned after the completion of her final exams for the summer for her freshman year. And she felt that during finals was pretty stressful for her. She had a lot of anxiety and during this time she started to have increased frequency, a little bit of urgency, increased blood in the stool. We'll talk more about her symptoms in a second. But then she returned home, and she expected the symptoms to go away, but they didn't. The symptoms continued to persist for 3 weeks. So, at this time, she decided to call the office and schedule a relatively urgent follow-up for the first time since starting college. When she had been seen we had no labs, we had no stool studies, and she was doing well all until final exams may have triggered a flare.

So, these are her symptoms. She had four diarrhea bowel movements daily, mostly with blood grossly. She had one nocturnal bowel movement occasionally every other day. Some cramping abdominal pain prior to these bowel movements, mainly in the lower portion of her abdomen. And she had some urgency associated with bowel movements and needed to run to the bathroom, but she had no incontinence.

So, what do we do when we see her? We see her, she looks pretty well. She tells us this story about how she thinks finals triggered her flare. And so, we look for stool studies. We get stool studies to see, does she have a calprotectin that is elevated. Calprotectin for us is not a point of care test. The calprotectin we send from the clinic is pending. She does send stool infectious studies to rule out infection triggering a flare. They come back later that evening, a GI PCR panel, which is negative, and a C. Diff panel, which is negative. Then we order labs. The labs are pending and don't result until the next day. So, none of these things help us make a decision in the clinic. We have a patient who now has moderate symptoms. We have stool infectious studies that return in the evening that are negative, but we don't know that at the time of clinic, we have a calprotectin that's still pending, and we have labs that are still pending that evening when the parents want to know what to do.

However, at our center, we have intestinal ultrasound, and this is what we use here. And here I highlighted in the colon picture, you can see the left side where she had disease. And what we do is without fasting, without preparation, we take the probe and we put it on the patient in the left lower quadrant and we're able to see disease activity or not. And this is how we use this as a flare or primary assessment for any of our patients with symptoms in colitis. And here's what we see. Here you have a sigmoid colon that is moving through your screen. You may have never seen an intestinal ultrasound video loop, but what I'm going to tell you is that inflammation in inflammatory bowel disease, whether it's ulcerative colitis or Crohn's disease, is transmural. And inflammation represents as two things, in the body and in the intestines. This represents as increased bowel wall thickness and increased blood flow, or hyperemia. And here you can see a thickened sigmoid colon and red and blue. That presence of doppler signal in hyperemia. This is consistent with active ulcerative colitis in the left colon and it's moderate. There's thickening, there's inflammatory fat surrounding the bowel that you see it piercing through, and there's a pretty persistent hyperemia signal that's actually more moderate to severe than the thickening would suggest. This suggests overall a good amount of activity going on.

Now, if you remember, she has a history of left-sided ulcerative colitis. We don't stop with the ultrasound probe with the left side and if she was actually getting a colonoscopy, you may only perform a flexible sigmoidoscopy. However, the advantage of ultrasound as a non-invasive technique is that we can view the entire colon. So, what do we do? We move on, we go to the transverse colon, and here you can see the same thing. The transverse colon has increased bowel wall thickness, increased blood flow consistent with moderate to severe disease activity. Now that has extended into the transverse colon. So, she no longer has left-sided ulcerative colitis, but now she has extensive ulcerative colitis.

However, we're not done there. We're going to take the probe; we're going to move it to the right side of the abdomen. And here you can see the ascending colon, the same picture, increased bowel wall thickness and hyperemia. So, you can see the layers of the bowel wall here that go white, black, white, black, white, the submucosal layer in ulcerative colitis driving the inflammation with all the hyperemia and thickening tied to that submucosal layer. And now she has pancolitis, not just left-sided, not extensive colitis, but pancolitis on mesalamine with the absence of infection. So, when we take this assessment, we now have a 19-year-old female with disease extension from left-sided ulcerative colitis based on intestinal ultrasound now with moderate bowel wall thickening throughout the entire colon. And this is consistent with her moderate clinical symptoms in the absence of triggering GI infections.”