A 66-Year-Old Woman With Ulcerative Colitis

DR PARKER: Mrs F is a 66-year-old woman troubled by loose, bloody bowel movements. A retired professor of psychology, widowed and with 1 son, she remains active professionally and socially. She has both Medicare and commercial indemnity insurance coverage. She first noticed blood on the toilet tissue in 1993. In 1994, a flexible sigmoidoscopy for hematochezia revealed a “friable appearance, edema, and a granular appearance in the rectum.” Biopsy results showed “chronic active colitis, severe without granulomas or dysplasia.” She was diagnosed with ulcerative proctitis. Subsequently, a flexible sigmoidoscopy showed extension of disease above the rectum. Initially,Cortenemaswerehelpful,butlosttheirefficacyover time. She finds the unpredictable urgency to defecate increasingly bothersome, and fears traveling to places without easily accessible bathrooms. She has not experienced fever, weight loss, or significant abdominal pain. She is not certain if prednisone taken for her severe asthma has improved her colitis. In 1996, she started taking warfarin sodium for chronic atrial fibrillation after unsuccessful cardioversion. She had an increase in loose stools with frank bleeding, at times up to 9 stools daily. Often, she wears pads to protect herself from fecal incontinence. Mrs F expresses some concern about the increased risk of colon cancer, but seems more troubled by the thought of a colostomy and how it might affect her sexual life and activities such as swimming. Her asthma remains severe with a peak flow between 150 to 200 L/m. In 1997, Mrs F suffered 2 bouts of pneumonia, and therefore felt less willing to entertain the idea of immunosuppressive drugs. Her medical history includes anaphylaxis to several food dyes, and an exacerbation of her asthma with aspirin, which has precluded the use of any aspirin-containing drugs for her colitis. Family history is notable for her sister being diagnosed with Crohn disease in her 60s. Her current medications include prednisone 10 mg daily, digoxin 0.25 mg daily, warfarin 5 mg daily, albuterol 2 puffs 4 times daily, zileuton 1200 mg twice daily, verapamil hydrochlorideasneeded,andepinephrine injection0.3mgasneeded. On physical examination, her vital signs are normal. Lungs reveal wheezing with prolonged expiration. Cardiac examination findings reveal an irregularly irregular rhythm with a grade I/VI systolic murmur. Her abdomen is slightly distended, with normal bowel sounds and without tenderness or masses. Hematocrit and sedimentation rate are normal. In summary, Mrs F has escalating symptoms of colitis and is intolerant or unable to take many of the usual medications such as mesalamine or 6-mercaptopurine (6-MP) due to allergies or her concerns about immune suppression. Her rectal bleeding is complicated by her need for anticoagulation for atrial fibrillation. She feels that the quality of her daily life is impaired by the unpredictability of loose, bloody bowel movements. She and her physicians are weighing the risks and benefits of further medical therapy vs surgical intervention.