Inflammatory Bowel Disease — Clinical Case

DCE Long Case

Patient brief (provided to trainee)

Patient: Ms Sarah Williams, 32 years old. [1]

Presenting complaint: Five days of worsening bloody diarrhoea (10 stools per day with urgency and tenesmus), cramping lower abdominal pain, and low-grade fevers. She has also noticed tender red lumps on her shins that appeared 2 days ago. [1]

Past history:

• Ulcerative colitis (pancolitis) diagnosed 6 years ago after presenting with bloody diarrhoeum. Initially managed with mesalazine, then azathioprine added 2 years ago after a moderate flare.
• Erythema nodosum and episcleritis during two previous flares.
• Iron deficiency anaemia.
• No surgical history. [1]

Current medications:

• Mesalazine 2 g daily
• Azathioprine 150 mg daily (2 mg/kg)
• Ferrous fumarate 200 mg daily [1]

Social history:

• Primary school teacher, single, lives with a flatmate. Non-smoker (ex-smoker, quit 8 years ago). Drinks alcohol occasionally. [1]

Examination findings (trainee elicits):

• General: comfortable but looks flushed. Cushingoid features from a previous steroid course.
• Skin: tender erythematous nodules on anterior shins (erythema nodosum), no pyoderma gangrenosum.
• Eyes: no episcleritis or uveitis.
• Abdomen: soft, mild left iliac fossa tenderness, no guarding or rebound. No hepatosplenomegaly. Bowel sounds present.
• Perianal: no fissure, fistula or skin tag.
• Joints: no active peripheral arthritis. [1]

Investigations:

• Hb 102 g/L (baseline 120), MCV 78 fL, WCC 13.2, platelets 450
• CRP 48 mg/L, ESR 38 mm/h
• Albumin 31 g/L
• Iron studies: ferritin 8 microg/L, transferrin saturation 12 per cent
• Na 136, K 3.8, creatinine 68, LFTs normal
• Stool: sent for culture and C. difficile toxin — pending
• Abdominal X-ray: no toxic megacolon, no free gas [1]

Candidate's structured presentation (model)

Opening statement: [1]

"Ms Williams is a 32-year-old primary school teacher who presents with a 5-day history of worsening bloody diarrhoea, abdominal cramping and fever, in the context of a 6-year history of extensive ulcerative colitis. She is on mesalazine and azathioprine. [1]

Her main problems are:

1. Acute severe ulcerative colitis — Truelove-Witts severe (more than 6 bloody stools, temperature 38.0, heart rate 96, haemoglobin 102, CRP 48)
2. Extraintestinal manifestation — erythema nodosum, which is activity-related and should resolve with bowel treatment
3. Iron deficiency anaemia — ferritin 8, transferrin saturation 12 per cent
4. Steroid-refractory risk — she is already on azathioprine 2 mg/kg and still flaring severely
5. VTE risk — acute severe colitis is a prothrombotic state
6. Colitis surveillance — 6 years of pancolitis; surveillance begins at 8 years, so she is due in 2 years [1]

My immediate priorities are hospital admission for IV hydrocortisone, stool studies to exclude C. difficile, flexible sigmoidoscopy to assess severity, DVT prophylaxis, IV iron repletion, and day-3 assessment for steroid response. If steroid-refractory, I will proceed to infliximab rescue therapy." [1]

Investigation summary: [1]

"Her CRP of 48 and thrombocytosis of 450 confirm active inflammation. Her haemoglobin of 102 with MCV 78, ferritin of 8 and transferrin saturation of 12 per cent confirm iron deficiency anaemia from chronic blood loss. Her albumin of 31 reflects the acute phase response and protein loss through the inflamed mucosa. The stool culture and C. difficile toxin are pending — C. difficile infection must be excluded because it is a common trigger for UC flares and requires specific treatment with oral vancomycin or fidaxomicin. Her abdominal X-ray excludes toxic megacolon." [1]

Management plan: [1]

1. Admit and stabilise — IV fluids, electrolyte correction (potassium, magnesium), DVT prophylaxis with enoxaparin 40 mg SC daily.
2. IV hydrocortisone 100 mg QID — first-line for Truelove-Witts severe disease. Assess response at day 3.
3. Stool studies — await culture and C. difficile toxin. If positive for C. difficile, add oral vancomycin 125 mg QID.
4. Flexible sigmoidoscopy (unprepared) — to assess Mayo endoscopic subscore and obtain biopsies for CMV (a common cause of steroid-refractory colitis in immunosuppressed patients).
5. IV iron — ferric carboxymaltose 1 g IV (oral iron is poorly tolerated in active colitis and may worsen oxidative stress).
6. Day-3 assessment — Oxford criteria. If stool frequency still more than 8/day, or CRP more than 45 with stool frequency 3 to 8/day, proceed to rescue therapy.
7. Rescue therapy — infliximab 5 mg/kg single dose (or ciclosporin 2 mg/kg/day IV if infliximab contraindicated).
8. Maintenance escalation — if she responds to rescue, plan maintenance biologic (infliximab every 8 weeks, vedolizumab, or tofacitinib).
9. Surgical review from admission — early involvement of colorectal surgery.
10. Erythema nodosum — will resolve with bowel treatment; no specific therapy needed.
11. Surveillance — schedule chromoendoscopy at 8 years from UC diagnosis (2 years from now).
12. Bone health — DEXA and calcium/vitamin D if prolonged steroid course. [1]

Examiner discussion questions

Q: "Why does she need DVT prophylaxis?" [1]

"Acute severe colitis is a prothrombotic state. The combination of inflammation, thrombocytosis, immobilisation during hospitalisation, and potential dehydration increases the risk of venous thromboembolism. Studies have shown that patients hospitalised with acute severe UC have a VTE risk comparable to post-surgical patients. Pharmacological DVT prophylaxis with low-molecular-weight heparin (enoxaparin 40 mg SC daily) is recommended for all hospitalised patients with acute severe colitis unless contraindicated. Importantly, heparin does not worsen the rectal bleeding from colitis — the bleeding is mucosal, not from the venous system." [1]

Q: "What if her stool comes back positive for C. difficile?" [1]

"C. difficile infection is a common trigger for UC flares and must be excluded in every acute presentation. If positive, I would add targeted therapy — oral vancomycin 125 mg QID for 10 to 14 days (or fidaxomicin 200 mg BID). I would still proceed with IV steroids because the colitis flare is driving the severe presentation, but I would not start immunosuppressive rescue therapy (infliximab or ciclosporin) until the C. difficile is being treated, because immunosuppression in the setting of active C. difficile can lead to toxic megacolon and sepsis. If she fails to respond to steroids plus vancomycin, I would involve infectious diseases and consider the risk-benefit of rescue therapy carefully." [1]

Q: "Day 3 comes. Her stool frequency is 7 per day and CRP is 32. What do you do?" [1]

"This does not meet the Oxford criteria for predicted colectomy (which requires either stool frequency more than 8/day, or CRP more than 45 with stool frequency 3 to 8/day). Her CRP of 32 is below 45, and her stool frequency of 7 is in the 3 to 8 range — so the CRP criterion is not met. She is showing a partial response to steroids. I would continue IV steroids for another 2 to 3 days and reassess. If she continues to improve, I would transition to oral prednisone and plan an outpatient maintenance escalation. If she plateaus or worsens, I would proceed to rescue therapy. The key is ongoing close monitoring — the Oxford criteria are a guide, not an absolute rule, and clinical judgement applies." [1]

Q: "She responds to steroids. How do you escalate her maintenance therapy?" [1]

"She has now proven to be steroid-dependent on azathioprine 2 mg/kg — she needs escalation to a biologic or small molecule. Before starting any biologic, I would screen for latent TB (quantiferon-Gold, chest X-ray), hepatitis B and C, HIV, and arrange a cardiology review if she has cardiovascular risk factors. The options are:

• Infliximab 5 mg/kg at weeks 0, 2, 6, then every 8 weeks, continued in combination with her azathioprine to reduce immunogenicity
• Adalimumab 160 mg SC, then 80 mg at week 2, then 40 mg every other week
• Vedolizumab 300 mg IV at weeks 0, 2, 6, then every 8 weeks — gut-selective with no systemic immunosuppression
• Tofacitinib 10 mg BID for 8 weeks then 5 mg BID — oral, rapid onset, but I would be cautious given cardiovascular and malignancy risk signals in older patients [1]

For a 32-year-old woman with no comorbidities, infliximab combination with azathioprine is a strong first choice — it has the best evidence for mucosal healing in this context. The target is endoscopic healing (Mayo 0 to 1) assessed at 6 to 9 months." [1]

Q: "What is her long-term colorectal cancer risk and surveillance plan?" [1]

"She has had extensive colitis for 6 years. Her colorectal cancer risk begins to increase at 8 to 10 years from diagnosis. Standard surveillance starts at 8 years and is performed every 1 to 2 years. She does not have PSC, so she follows the standard schedule. The technique is dye-spray chromoendoscopy with targeted biopsies — this detects dysplasia 2 to 3 times more effectively than white-light colonoscopy with random biopsies. If dysplasia is found, the management depends on whether it is visible (polypoid or non-polypoid) or invisible, and whether it is low-grade or high-grade. Most visible dysplastic lesions can be removed endoscopically. Colectomy is reserved for unresectable dysplasia, multifocal high-grade dysplasia, or confirmed carcinoma. 5-ASA maintenance may have a chemopreventive effect, which is another reason to optimise her maintenance therapy." [1]

DCE Short Case — Abdominal and Skin Examination

Instruction

"Examine this patient's abdominal system. You have 7 minutes for examination and 8 minutes for discussion." [1]

Key signs the patient demonstrates

• General inspection: Cushingoid features (moon face, central obesity) from chronic steroid use; pallor suggesting anaemia
• Skin: Erythema nodosum (tender red nodules on anterior shins); aphthous ulceration on oral mucosa
• Hands: No clubbing; no peripheral arthritis today
• Eyes: No episcleritis or uveitis
• Abdomen: Soft, mild left iliac fossa tenderness; no masses; no scars; no stoma; no hepatosplenomegaly
• Perianal: No fissure, fistula or skin tag [1]

Systematic routine

1. End of bed — observe for Cushingoid features, cachexia, pallor, obvious skin lesions (erythema nodosum on shins, pyoderma gangrenosum on legs).
2. Hands and arms — clubbing (Crohn's, PSC-UC), palmar erythema, aphthous ulceration, check for peripheral arthritis (swollen or tender joints, especially knees and ankles).
3. Eyes — episcleritis (red conjunctiva without pain), uveitis (painful red eye with photophobia).
4. Mouth — aphthous stomatitis (shallow painful ulcers on buccal mucosa, tongue or lips).
5. Skin of trunk and legs — erythema nodosum (tender red nodules, anterior shins), pyoderma gangrenosum (ulcer with undermined edges, usually lower legs).
6. Abdomen — inspect for scars (right iliac fossa scar from ileocaecal resection in Crohn's, midline scar from colectomy), stomas; palpate for tenderness, masses (right iliac fossa mass in Crohn's), hepatosplenomegaly; auscultate bowel sounds.
7. Perineum — skin tags, fissures, fistulae, abscess, scarring (the most commonly missed area — always examine).
8. Joints and spine — peripheral arthritis (knees, ankles), sacroiliac tenderness, reduced lumbar mobility (ankylosing spondylitis). [1]

Presentation template

"I examined Ms Williams' abdominal system. She has Cushingoid features with a moon face and central obesity, consistent with corticosteroid use. There are tender erythematous nodules on the anterior shins bilaterally, consistent with erythema nodosum. There is an aphthous ulcer on the buccal mucosa. [1]

There is no clubbing, peripheral arthritis, episcleritis or uveitis. The abdomen is soft with mild left iliac fossa tenderness. There are no palpable masses, no hepatosplenomegaly, and no surgical scars or stomas. Bowel sounds are normal. On perianal examination, there is no fissure, fistula, skin tag or abscess. [1]

These findings are consistent with an ulcerative colitis flare with an activity-related extraintestinal manifestation — erythema nodosum and aphthous stomatitis. The erythema nodosum should resolve with treatment of the underlying bowel disease. I would like to take a full medication and surgical history, check inflammatory markers and faecal calprotectin, organise stool studies, and proceed to flexible sigmoidoscopy to assess severity." [1]

Discussion template

1. Summarise findings → "consistent with active ulcerative colitis with activity-related extraintestinal manifestations (erythema nodosum, aphthous stomatitis)."
2. Classify the EIMs → "Erythema nodosum and aphthous stomatitis are activity-related — they track bowel inflammation and resolve with gut treatment. This is distinct from activity-independent manifestations like PSC, axial spondyloarthritis, uveitis and pyoderma gangrenosum, which run their own course."
3. Differential of the abdominal findings → "The left iliac fossa tenderness is consistent with colitis. In Crohn's disease, I would look for a right iliac fossa mass, perianal disease, and signs of previous surgery."
4. Management → "Hospital admission for IV steroids given the severity, stool studies to exclude C. difficile, flexible sigmoidoscopy, DVT prophylaxis, and day-3 assessment for steroid response."
5. Communication → "I would explain the flare and treatment plan, reassure her that the erythema nodosum will improve with the bowel treatment, and discuss her long-term management including surveillance timeline." [1]