Presentation
Patient presented to us with bloody diarrhea for last 6 months with tenesmus. He also noticed unintentional weight loss with H/O frequent low-grade fever.
Patient Data
Colonoscopy findings reveal:
seen up to terminal ileum
perianal area: normal
anal canal: normal
rectum, colon and terminal ileum: diffuse mucosal edema, erythema, granularity, friability, ulceration and loss of vascular pattern involving the rectum and extending up to descending colon. Similar lesions were seen at the ascending colon and cecum. The transverse colon and terminal ileum were free of lesions.
biopsy was taken
Histopathology: Sections show fragments of colonic mucosa. The surface is ulcerated. Lamina propria shows lymphoplasmacytic infiltration, neutrophils and eosinophils. A few glands reveal crypt abscesses. Dx: features suggestive of IBD (ulcerative colitis).
Case Discussion
After a diagnosis of ulcerative colitis, the patient was started on 5-ASA therapy. There were no features of acute ulcerative colitis at the time of admission. So patient was discharged later with proper medication and was asked to come for regular follow-up at the OPD.
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