Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with increased stool frequency, urgency, and nocturnal defecation. Reports associated abdominal cramping, pelvic discomfort, and occasional hematochezia. Symptoms are consistent with acute pouchitis. Patient reports prior successful response to antibiotic therapy. Denies fever, systemic toxicity, or extra-intestinal manifestations.
Clinical Examination Findings
Abdominal exam: Soft, non-distended, mild tenderness in the lower quadrants/pelvic region. Bowel sounds are hyperactive. No signs of peritonitis or guarding. Perianal exam: No evidence of abscess, fistula, or skin tags. Pouchoscopy (if performed): Diffuse erythema, edema, loss of vascular pattern, and friability of the pouch mucosa.
Treatment Protocol
Initiate empiric antibiotic therapy: Ciprofloxacin 500mg BID or Metronidazole 500mg TID for 14 days. Advise patient to maintain adequate hydration. Recommend follow-up in 2 weeks to assess clinical response. If refractory, consider pouchoscopy with biopsy and stool studies (C. diff, pathogens).