Ulcerative Colitis: A Detailed Patient Case Study

Introduction: Overview of Ulcerative Colitis

Ulcerative colitis, also known as chronic ulceration of the intestines, is a fairly common disorder estimated to have an incidence of 1 in 1,000 persons in western countries (Kefalides & Hanauer, 2002). Ulcerative colitis and Crohn's disease together comprise the spectrum of inflammatory bowel disease. These diseases affect approximately 400,000 individuals in the United States, and their economic impact has been estimated at $2 billion annually (ibid). Both diseases are viewed as serious and severe digestive afflictions that can cause life-impairing symptoms, necessitate long-term dependence on powerful drugs, and often result in debilitating surgery and even death. Both are classified under the medical rubric of Inflammatory Bowel Disease (IBD) (Hoffman, 1995).

Both ulcerative colitis and Crohn's disease share many epidemiologic features. They can affect individuals in all age groups, although they most commonly affect individuals over forty. Ulcerative colitis is, however, more prevalent among females, affecting 30 percent more females than males (Ulcerative Colitis, 2004). While ulcerative colitis is also more likely to occur in middle-to-older age groups, there are increasing indications of its occurrence among younger people. "The incidence of ulcerative colitis peaks in people aged 15–25 years and in people aged 55–65 years, although it can occur in people of any age" (ibid).¹

Significantly, a radical change of environment and diet can trigger the disease, although there is also a genetic component. "Approximately 10% to 30% of patients with inflammatory bowel disease report having a family member with inflammatory bowel disease" (Kefalides & Hanauer, 2002).² Inheritance appears to play a role in about 20 percent of patients with ulcerative colitis. In most families with relatives who have IBD, those relatives are affected by the same type of inflammatory bowel disease (Questions & Answers About Ulcerative Colitis, 2004).

Certain environmental factors must also be considered in the assessment and diagnosis of the disease. These include stress and smoking, both of which can be strong contributing factors.³ "However, it is currently not known whether the disease has a genetic and/or autoimmune etiology or is related to a broad array of contributing factors, such as diet and infection" (ibid).

Patient Presentation and Background

The patient under consideration is a 26-year-old woman. She has a history of dysmenorrhea — painful menstruation usually accompanied by abdominal cramping — and an eighteen-month history of episodic diarrhea. From time to time she has observed blood in her stools. She also reported continually having painful sores in her mouth. The symptoms she had experienced became more severe in the weeks prior to the consultation, with a recent increase in diarrhea and more evidence of blood in the stools. These symptoms were accompanied by an increase in abdominal cramping. She also reported intermittent, non-excessive fever and a marked decrease in appetite over the past two months.

It was important to rule out external factors that might bear on her condition. In this regard, she reported that she had not traveled to other countries or regions in the past year, which simplified the diagnostic picture.⁴

In drawing up a clinical presentation, it was also important to consider factors that might indicate other diagnostic possibilities — in particular, to distinguish between pathological causes of diarrhea and irritable bowel syndrome (IBS). IBS is "the most common cause of loose bowel movements associated with abdominal cramping; in this condition, loose bowel movements often alternate with constipation" (Kefalides & Hanauer, 2002). However, IBS is not usually associated with blood in the stool, which is more characteristic of inflammatory bowel disease. As the literature notes: "The presence of blood or pus (fecal leukocytes) is associated with inflammation or neoplasia; in contrast, mucus is a normal constituent of stool, and neither its presence nor its absence has any specificity for either condition" (ibid).

Another factor to consider was that the patient had experienced a marked degree of weight loss over the past three months — another finding pointing toward colitis rather than IBS. It was also necessary to rule out the use of antibiotics as a contributory factor, given the associated risk of Clostridium difficile infection. The patient had not undergone any significant antibiotic treatment in recent months.

On further questioning, the patient reported that her bowel movements were sometimes murky and very dark in color. She also noted that her bowel movements were very frequent — between three and five per day, as well as frequent movements during the night. She attributed evidence of blood to hemorrhoids, although this seemed unlikely given the absence of any skin tags.

Further Patient History

The only medication she was taking was vitamin supplements. Her clinical history showed no allergies and no previous hospitalizations or surgery, except for an appendectomy at age fourteen. She stated that she did not consume alcohol except on special occasions, when she would have fewer than three drinks.

Her family history suggested a hereditary and genetic predisposition to ulcerative colitis. Both her mother and aunt had suffered for years from spastic colon syndrome, and there had also been episodes of colitis in her uncle and one of her nephews.

Another important factor was that she was an entrepreneur who experienced extreme and continuous stress from running a small business and managing financial concerns. While some research has found that stress is not a definitive factor in this condition,⁵ her very high stress level was considered relevant to the clinical picture. Notably, she was also a fairly heavy smoker.

The patterns of her personal history clearly indicated a strong possibility of ulcerative colitis. This initial assessment was based on the high stress factor, smoking, and — most importantly — blood in the stools, which was indicative of inflammatory diarrhea with loss of mucosal integrity. The diarrhea also pointed to inflammatory bowel disease. While nocturnal bowel movements can indicate IBS, they can equally indicate IBD. Inflammatory bowel disease and IBS share several overlapping symptoms, making careful differential diagnosis essential.⁶

It was also important to review previous drug and medication use. Anti-inflammatory drugs (NSAIDs) such as ibuprofen are well known to disrupt gastrointestinal mucosal integrity and may precipitate inflammatory bowel disease. The family history indicating a genetic predisposition — with at least three close relatives affected by colitis or related inflammatory disease — may also reflect an inherited propensity for either IBD or IBS, depending on the clinical validity of the history provided.

All of these factors supported the assumption that inflammatory bowel disease was the cause of this patient's symptoms. She also appeared extremely nervous, lending further credence to the possible diagnosis. Her initial history and presentation aligned with several classic symptoms of inflammatory or ulcerative colitis. The most common symptoms of ulcerative colitis include constipation accompanied by blood or mucus in the stools, "the urge to defecate with only a scanty bowel movement," and may progress to "severe fatigue, weight loss, loss of appetite, fever and occasionally painful joints" (Hoffman, 1995). On questioning, the patient confirmed deep fatigue following only slight physical or mental exertion, as well as sore joints and shoulder pains — findings consistent with these classic indicators.