From the Guidelines
I strongly recommend resection of the affected areas of the colon and rectum for this patient. The clinical presentation suggests a severe and chronic condition that has not responded to medical therapy, with symptoms including bloody diarrhea, abdominal pain, fecal incontinence, and significant weight loss over 10 months. The CT findings show wall thickening in the descending colon, sigmoid, and rectum, while the histopathology reveals atrophic crypts, musculized capillaries, and fibrin thrombi, which are characteristic of ischemic colitis or chronic injury. Importantly, the patient has failed trials of corticosteroids, mesalazine, and antibiotics (Cipro with metronidazole), indicating that medical management is ineffective 1.
In cases of chronic conditions that do not respond to conservative treatment, surgical resection of the affected bowel segments is often the definitive treatment to prevent further complications such as strictures, perforation, or ongoing blood loss. The patient's lack of response to steroids and antibiotics rules out inflammatory bowel disease and infectious causes as the primary issue, while the histopathology findings are inconsistent with vasculitis, making options like infliximab, anti-tuberculosis therapy, or cyclophosphamide less appropriate for this case 1.
Key considerations in this decision include:
- The patient's significant weight loss and symptoms suggestive of malabsorption or chronic inflammation
- The failure of medical therapy to improve symptoms or induce remission
- The presence of wall thickening and histopathological changes consistent with chronic injury or ischemia
- The need to prevent further complications and improve quality of life through definitive treatment
Given these considerations and the evidence from recent guidelines 1, surgical resection of the affected areas is the most appropriate next step to address the patient's condition and prevent further morbidity. Post-operatively, the patient will need nutritional support and close follow-up to monitor for recurrence and manage any potential complications.
From the Research
Treatment Options for Ulcerative Colitis
The patient presents with symptoms of ulcerative colitis, including bloody diarrhea, abdominal pain, fecal incontinence, and significant weight loss. Given the patient's inadequate response to medical therapy, including steroids, mesalazine, and antibiotics, alternative treatment options should be considered.
Infliximab Therapy
- Infliximab is effective for the treatment of moderate-to-severe ulcerative colitis (UC) and is recommended for patients who have had an inadequate response to medical therapy 2.
- Combination therapy with infliximab and azathioprine has been shown to be more effective than azathioprine alone in achieving steroid-free clinical remission in patients with acute severe ulcerative colitis 3.
- Infliximab has also been shown to be effective in combination with azathioprine for the treatment of Crohn's disease, with higher remission rates compared to infliximab or azathioprine monotherapy 4, 5.
Other Treatment Options
- Immunomodulators, such as azathioprine, are a class of drugs that attenuate the underlying inflammatory processes of UC and Crohn's disease, and are often used in combination with biologic agents like infliximab 6.
- Corticosteroids and cyclophosphamide may be considered as alternative treatment options, although their use is often limited by side effects and toxicity.
- Resection of the affected areas of the colon and rectum may be necessary in severe cases of UC that are unresponsive to medical therapy.
Recommended Treatment
Based on the available evidence, infliximab therapy, either alone or in combination with azathioprine, is a recommended treatment option for this patient. The use of infliximab has been shown to be effective in achieving clinical remission and improving quality of life in patients with UC, and its combination with azathioprine may provide additional benefits in terms of efficacy and safety 2, 3, 4, 5.