What is the diagnosis and treatment for a patient with a 3-month history of hematochezia (passing blood and mucus in stools) at least once daily, without severe bleeding, and a history of oral ulcers?

Diagnosis: Inflammatory Bowel Disease (Crohn's Disease or Ulcerative Colitis)

The combination of 3 months of bloody mucoid stools with oral ulcers strongly suggests inflammatory bowel disease, most likely Crohn's disease given the oral manifestations, and requires immediate colonoscopy with biopsy for definitive diagnosis followed by initiation of immunosuppressive therapy. 1, 2

Clinical Presentation Analysis

This patient's symptom constellation is highly characteristic of IBD:

• Bloody diarrhea with mucus lasting >30 days meets the definition of chronic diarrhea and indicates persistent inflammatory bowel disease rather than infectious etiology 1
• Oral ulcers (aphthous stomatitis) occur in 10-20% of IBD patients and represent extraintestinal manifestations, more commonly associated with Crohn's disease than ulcerative colitis 3, 2
• Non-massive bleeding ("not gushing blood") indicates mucosal inflammation rather than life-threatening hemorrhage, typical of IBD presentation 1, 2

The chronic nature (3 months) effectively rules out infectious causes, which typically resolve within 7-14 days even without treatment 1.

Immediate Diagnostic Workup

Hemodynamic Assessment

• Calculate shock index (heart rate ÷ systolic blood pressure)—a value >1 indicates instability requiring ICU admission 4
• Check orthostatic vital signs (BP drop >20 mmHg or HR increase >20 bpm when standing indicates significant blood loss) 4
• Perform digital rectal examination to confirm blood character and exclude anorectal pathology 1, 4

Laboratory Evaluation

• Complete blood count to assess for anemia, leukopenia (suggesting autoimmune enteropathy), or leukemia 3, 5
• Fecal calprotectin and lactoferrin—elevated levels indicate intestinal inflammation and correlate with endoscopic severity in IBD 1
• Stool studies for infectious causes: Shiga toxin-producing E. coli (STEC), Salmonella, Shigella, Campylobacter, and Yersinia—critical to exclude before starting immunosuppression 1, 6
• C. difficile toxin testing, especially if any recent antibiotic exposure 1
• HIV antibody and syphilis serology given oral ulcers 3

Endoscopic Evaluation

For hemodynamically stable patients (which this patient appears to be), proceed with colonoscopy as the definitive diagnostic procedure 1, 4:

• Ileocolonoscopy with multiple biopsies from all colonic segments and terminal ileum is mandatory for diagnosis 2
• Pathognomonic findings for ulcerative colitis: continuous colonic inflammation from rectum extending proximally, with erythema, loss of vascular pattern, granularity, friability, and ulcerations with distinct demarcation between inflamed and non-inflamed bowel 2
• Pathognomonic findings for Crohn's disease: skip lesions (patchy inflammation), cobblestoning, aphthous ulcers, and potential terminal ileal involvement 1, 6
• Histopathology confirms diagnosis: decreased crypt density, crypt architectural distortion, heavy diffuse transmucosal inflammation without granulomas (UC) versus transmural inflammation with non-caseating granulomas (Crohn's) 2

Upper endoscopy (EGD) should also be performed to evaluate for upper GI Crohn's involvement and assess oral ulcer etiology 1, 6.

Treatment Algorithm

Initial Management for Mild-Moderate Disease

If ulcerative colitis is confirmed:

• For proctitis: topical 5-aminosalicylic acid (5-ASA) suppositories or enemas as first-line therapy 2
• For extensive disease: combination of oral 5-ASA (2.4-4.8 g/day) plus topical 5-ASA to induce remission 2
• Add oral corticosteroids (prednisone 40-60 mg/day) if inadequate response to 5-ASA within 2 weeks 2

If Crohn's disease is confirmed:

• Oral corticosteroids (prednisone 40-60 mg/day or budesonide 9 mg/day for ileal disease) for induction 2
• Immunomodulators (azathioprine 2-2.5 mg/kg/day or 6-mercaptopurine 1-1.5 mg/kg/day) for maintenance 2

Escalation to Biologic Therapy

For steroid-refractory or steroid-dependent disease, initiate anti-TNF therapy 7, 2:

• Infliximab dosing: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks for maintenance 7
• Indicated for moderately to severely active Crohn's disease or ulcerative colitis with inadequate response to conventional therapy 7
• Can be used in pediatric patients ≥6 years old 7
• Monitor for serious infections, tuberculosis reactivation, and hepatosplenic T-cell lymphoma (especially when combined with azathioprine/6-MP) 7

Treatment of Oral Ulcers

Concurrent management of oral manifestations 3:

• Clobetasol propionate 0.05% gel applied to oral ulcers 2-3 times daily 3
• Betamethasone sodium phosphate 0.5 mg in 10 mL water as rinse-and-spit four times daily for widespread ulcers 3
• Benzydamine hydrochloride rinse every 3 hours, particularly before eating 3
• Viscous lidocaine 2% (15 mL) as topical anesthetic before meals 3
• Treating the underlying IBD typically resolves oral ulceration 3

Critical Pitfalls to Avoid

• Never start immunosuppressive therapy before excluding infectious causes, particularly STEC, as antibiotics can precipitate hemolytic uremic syndrome 1, 6
• Do not delay colonoscopy to obtain stool studies—blood in stool for 3 months warrants immediate endoscopic evaluation regardless of stool test results 4
• Avoid empiric antibiotic therapy for bloody diarrhea before ruling out STEC infection 6
• Do not use antidiarrheal agents (loperamide, kaolin-pectin) as these can worsen outcomes in inflammatory conditions 6
• Failure to biopsy adequately (multiple sites, adequate depth) leads to missed diagnosis—obtain at least 2 biopsies from 5 different colonic sites plus terminal ileum 2
• Delaying biologic therapy in steroid-refractory disease increases risk of complications and need for emergency surgery 1

Indications for Emergency Surgery

Surgery is indicated if 1:

• Free perforation or generalized peritonitis develops
• Life-threatening hemorrhage with hemodynamic instability occurs
• Toxic megacolon refractory to medical management within 48-72 hours
• No improvement after second-line medical therapy (infliximab or cyclosporine)

Subtotal colectomy with ileostomy is the procedure of choice for emergency surgery in ulcerative colitis 1.

Monitoring and Maintenance

Once remission is achieved 2:

• Continue 5-ASA for ulcerative colitis maintenance (2.4 g/day minimum)
• Continue immunomodulators (azathioprine/6-MP) or biologic therapy for Crohn's disease
• Monitor complete blood count every 3 months on immunomodulators
• Surveillance colonoscopy at 8 years after diagnosis, then every 1-3 years depending on risk factors
• Assess for extraintestinal manifestations (arthritis, uveitis, primary sclerosing cholangitis)