From the Guidelines
I strongly recommend infliximab (option 1) for this patient, as the clinical presentation and failure of previous medical management suggest a severe case of inflammatory bowel disease that may benefit from biologic therapy. The patient's symptoms of bloody diarrhea, abdominal pain, fecal incontinence, and significant weight loss, along with the CT findings of wall thickening in the descending colon, sigmoid, and rectum, are consistent with a diagnosis of ulcerative colitis or Crohn's disease [ 1 ]. The fact that the patient has not responded to trials of steroids, mesalazine, and antibiotics indicates that medical management has failed, and biologic therapy such as infliximab may be necessary to induce remission [ 1 ].
According to the guidelines for the management of inflammatory bowel disease in adults, infliximab 5 mg/kg is effective for active disease, and may be considered in patients who have failed other medical therapies [ 1 ]. The patient's lack of response to previous treatments and the presence of severe symptoms suggest that infliximab may be a suitable option.
Some key points to consider in this patient's management include:
- The patient's significant weight loss and malnutrition, which may require nutritional support during treatment [ 1 ]
- The presence of a sigmoid stricture, which may require close monitoring and possible surgical intervention if it worsens [ 1 ]
- The need for regular follow-up and monitoring of the patient's response to infliximab, as well as potential side effects [ 1 ]
Overall, infliximab (option 1) is the most appropriate recommendation for this patient, given the severity of their symptoms and the failure of previous medical management.
From the Research
Treatment Options for Ulcerative Colitis
The patient's symptoms, such as bloody diarrhea, abdominal pain, and significant weight loss, are consistent with ulcerative colitis (UC) 2. Given the patient's lack of response to mesalazine, corticosteroids, and antibiotics, alternative treatment options should be considered.
Biologic Therapies
- Infliximab, a biologic therapy, has been shown to be effective in inducing and maintaining clinical remission in patients with moderate-to-severe UC 3, 4, 5.
- The combination of infliximab and immunosuppressant therapy may be more effective than infliximab alone in achieving clinical remission 4.
- Vedolizumab, another biologic therapy, has been compared to infliximab and other advanced therapies, suggesting a potentially favorable efficacy-safety balance for vedolizumab 6.
Treatment Recommendations
Based on the evidence, the following treatment options could be considered:
- Infliximab, either alone or in combination with immunosuppressant therapy, may be an effective treatment option for this patient 3, 4, 5.
- Corticosteroids and cyclophosphamide may also be considered, although the evidence for this combination is limited.
- Resection of the affected areas of the colon and rectum may be necessary if medical therapy is unsuccessful.
Ruling Out Other Conditions
The patient's symptoms and test results have already ruled out other conditions such as tuberculosis, hepatitis B, and HIV 2. The patient's lack of response to antibiotics suggests that an infectious cause is unlikely.
Next Steps
Given the patient's severe symptoms and lack of response to initial treatment, it is essential to consider biologic therapies, such as infliximab, as the next step in management 3, 4, 5.