Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents for follow-up of chronic pouchitis, refractory to multiple courses of antibiotics (e.g., ciprofloxacin, metronidazole). Reports persistent increased stool frequency (____/day), urgency, nocturnal defecation, and hematochezia. Denies fever or systemic symptoms. No recent changes in diet or medication adherence.
Clinical Examination Findings
Abdominal exam: Soft, non-distended, non-tender, no guarding or rebound. Bowel sounds present. Perianal exam: No evidence of perianal skin tags, fissures, or fistulae. Digital rectal exam (DRE) reveals pouch mucosa with friability, edema, and loss of vascular pattern consistent with chronic inflammation.
Treatment Protocol
Plan: Initiate biologic therapy (e.g., Vedolizumab or Infliximab) due to antibiotic-refractory status. Consider topical therapy (budesonide enemas) as adjunct. Monitor for secondary causes (e.g., cuffitis, Crohn’s disease of the pouch). Schedule pouchoscopy with biopsy to confirm histological activity and exclude dysplasia.