This is a case study of a 34-year-old man Thomas Waleir, who presented to General Practitioner (GP) as he was feeling very unwell for few weeks. The patient reported in 2010 that he has been experiencing persistent episodes of loose stools and diarrhoea and a lot of red bright blood as well as mucus also passing with stools. The symptoms then indicated that he had tenderness in abdomen and a feeling of enlarged liver. Moreover, Thomas Wailer also lost a significant weight and appeared dehydrated.
After 10 years, in 2020 he has been experiencing similar symptoms and therapies cannot control the symptoms. In this study, the discussion will focus on making diagnosis on the basis of symptoms and macroscopic or histological image, pathology behind the condition, mechanism of action of the drug and interpretation of the blood results.
Based on the symptoms as well as macroscopic and histological report it can be said that the patient might have acquired “Ulcerative Colitis” (Gajendran et al. 2019). Ulcerative colitis is one kind of inflammatory bowel disease (IBD) which results in inflammation as well as sores or (ulcers) in the digestive tract.
This colon disorder significantly affects the innermost large intestine lining as well as rectum (mayoclinic.org 2021). The symptoms of this disease are mainly diarrhea or loose stools often filled with red blood, rectal pain, abdominal pain as well as cramping rectal bleeding, urgency to defecate, incapacity to defecate despite urgency, fatigue, significant loss of weight as well as fever (mayoclinic.org 2021).
In case of Thomas Wailer all the symptoms are evident as he has been experiencing persistent episodes of loose stools and diarrhoea and a lot of red bright blood as well as mucus also passing with stools. Also, he is feeling pin in abdominal region, feeling fatigued and lost a significant weight and appeared dehydrated that indicated about he might have acquired Ulcerative Colitis.
Ulcerative colitis is one type of chronic inflammatory, idiopathic disease that occur in the colonic mucosa and initiate in the rectum and then extends proximally in a regular manner through in portions, or in the entire colon. Although in some individuals with left-sided colitis or proctitis might have inflammation’s caecal patch (Gajendran et al. 2019).
The pathology of ulcerative colitis is associated with defective function in the epithelial barrier, immune response, leukocyte recruitment, as well as microflora present in colon. Colonic mucin as well as maybe tight junctions are defective in the epithelial barrier, resulting in greater uptake of luminal antigens. The lamina propria present in mucosa possesses a higher number of active and developed dendritic cell, along with a significant number of toll-like receptors (TLRs), particularly TLR2 as well as TLR4.
Pathology of Ulcerative Colitis
In inflammatory conditions, there appears to be an unusual T-helper (Th) cell response, particularly Th2, which would be cytotoxic to epithelial cells (Lynch and Hsu 2017). Interleukin 13, tumor necrosis factor-alpha (TNF-alpha), along with natural killer T-cells are other factors related to immunity system that have a major role in the pathogenesis of ulcerative colitis. Irritable bowel illness results in an elevation in IgG, IgA, and IgM antibodies; although, individuals with ulcerative colitis have a greater rise in IgG1 antibodies (Ungaro et al. 2017).
On multiple fronts, leukocyte infiltration is influenced. In this disease, the chemoattractant CXCL8 is discharged at a greater rate, attracting leukocytes from the circulation to the mucosa. On the mucosal blood vessel's endothelial layer, there is an elevation of mucosal address in cellular adhesion molecule-1 (Mad-CAM1), which facilitates leukocyte adherence and extravasation within mucosal tissue (Lynch and Hsu 2017).
In Ulcerative colitis, doctors usually prescribe corticosteroid drugs that include budesonide as well as prednisone which are usually reserved for medium to severe ulcerative colitis and does not react to other treatments (crohnsandcolitis.org.uk 2021). The rationale behind prescribing this medication in Ulcerative colitis is that in this inflammatory disease the immune response is not normal as IG1 antibodies significantly increases and this drug is associated with lowering the response of immune system, so that they assist in decrease the body’s acute inflammation (crohnsandcolitis.org.uk 2021). By lowering increase in the IG antibodies and immune response this drug minimizes the pain.
Sulfasalazine is one type of disease modifying anti-rheumatic drug often prescribed in Ulcerative colitis. Sulfasalazine is a drug that is used in the treatment ulcerative colitis, a kind of bowel illness. This drug does not fully cure the ailment; however, it does assist with symptoms like fever, diarrhoea, stomach pain, and rectal bleeding. This medication is used to extend the period between attacks once an attack has been treated. Sulfasalazine functions by lowering gastrointestinal discomfort and edema (medlineplus.gov 2021).
This drug acts in the colon locally to reduce inflammation. Moreover, this drug functions across the body by hindering the production of the chemical termed as Prostaglandins which play various functions of the body including pain and inflammation (medlineplus.gov 2021). It has been found that, Sulfasalazine and one of the metabolites 5-aminosalicylic acid and sulphapyridine inhibit the functions of the B cell but not the function of T cell. Moreover, it suppresses the yield of IgM and IgG that associated with inflammation (Choi and Fenando 2020).
Use of Steroids
Furthermore, the component sulphapyridine disrupts and block the release of growth-related gene product-alpha, inflammatory chemokines interleukin-8, as well as monocyte chemotactic protein-1 (Choi and Fenando 2020).
In this inflammatory disease, the most prescribe immunosuppressive drugs is Azathioprine. Based on the symptoms that the patient presented here the most suitable drug of choice would be Azathioprine. Azathioprine (trade name is Imuran) is the drug which usually treats diseases that directly associated with the immune system (Timmer et al. 2016).
In ulcerative colitis the main cause of inflammation is the attack in the digestive system by the immunity system. In basics, Azathioprine decreases the amount of WBC in the body and interrupt the function of immune system. The mode of action of this medication is associated with inhibiting the synthesis of purine (Mohammadi and Kassim 2019). Azathioprine's toxicity is considered to be multifactorial, with transformation to 6-mercaptopurine (a purine antimetabolite), potential alkylation inhibition of thiol groups, suppression including pathways of biosynthesis of several nucleic acid (that prevent the cell proliferation which involved in the persistence and propagation of the immune reaction), as well as damage of DNA from the inclusion of thiopurine analogues all being thought to play a role (Mohammadi and Kassim 2019).
It has been seen that Purines are required to manufacture of DNA as well as RNA. By inhibition of synthesis of purine, very minimal amount of DNA and RNA are manufactured that required for synthesis of WBC, which cause immunosuppression (Timmer et al. 2016). By the above-mentioned mechanism Azathioprine suppresses the immune responses and provide relief to the patient.
From the first figure it can be said that it is usually a gross specimen of Ulcerative Colitis. It has been seen that mucosa’s hemorrhagic ulcerated appearance was there as well as it was continuous without skip areas.
The Colectomy specimen from the patient also showed a diffuse, and continuous involvement of distal colon along with mucosal erythema as well as granularity along with terminal ileum and sparing of the proximal colon. Moreover, it was evident that there was loss of the vascular appearance in the colon. Furthermore, in ulcerative colitis (the patient's sample), the histologic findings comprise crypt architectural deformation, crypt abscesses, as well as inflammatory cells in the mucosa (plasma cells, granulocytes and lymphocytes).
Unlike Crohn's disease, which causes transmural inflammation, ulcerative colitis causes inflammation only in the mucosa. Without indications of neutrophilic inflammation, persistent passive (quiescent) colitis with crypt architectural deformation and Paneth cell metaplasia.
Sulfasalazine in Ulcerative Colitis
From the laboratory findings it could be seen that the hemoglobin count is very low in the patient as it is only 81 grams per litter whereas the normal ranger of blood hemoglobin is 135 grams per litter (NCH library 2021). It has been seen that, in patients with ulcerative colitis 33.3 percent individuals have extremely low Hb level or anemia symptoms (crohnscolitisfoundation 2021). The most common indication is fatigue which is also evident in Thomas’s case. Moreover, the White blood cell count (WCC) is 12 × 109/L whereas the normal range is 4.5 to 11.0 × 109/L and that indicated about over immune response and presence of Ulcerative colitis.
Moreover, in liver function test it was seen that the ALP level or Alkaline Phosphatase level is 135 which is also very high as Values above 130 U/L are normally counted to be high (). Higher level ALP is a major concern of liver function as well as gallbladder. In addition, the AST blood test range is also quite high which is 68 units per liter and the usual range for AST is 10 units/L to 40 units per liter, and more than 50 units/L is very concerning (Mayo clinic 2021).
Hepatitis, mononucleosis, cirrhosis, as well as other liver illnesses can all be indicated by high AST levels in the blood. The blood test indicated that Amino Alanine transferase (ALT) level of the patient is 85 units/L whereas the normal range falls in between 7 units/L to 55 units and that also indicated about abnormal liver condition. Lastly the C-reactive Protein or CRP level indicated that it is 210 mg/L whereas the normal range falls in between 3 mg/L (Mayo clinic 2021). It clearly indicated that the patient is experiencing inflammation which is very commonly associated with Ulcerative colitis.
Ulcerative colitis is a chronic disease that requires lifelong management instead of a life-threatening illness. Nonetheless, it is a severe condition that can lead to major complications, particularly if the patient does not receive the proper therapy (National Health Service 2021). Arthritis, liver illness, ocular inflammation, severe dehydration, risk of severely bleeding, colon cancer as well as osteoporosis are all possible side effects of ulcerative colitis. Till now it is not very clear why these issues originate outside of the colon. Scientists believe that inflammation triggered by the immune system is to blame for these consequences (National Health Service 2021).
In the case study it was clearly mentioned that Thomas is presently lives with a stoma. It has been mentioned in various research that living with a stoma might have various adverse effects on the patients. When the patients start using stoma they eventually have to cope up with loss of control over the removal of their faeces as well as they might significantly encounter problems in sexual function, stigma, social isolation as well as changes in body image (Liao and Qin 2014).
It has been seen that because of the stoma bag people often feel embarrassed as well as the mood of them stay in lower side. They often start to feel anxious or depressed or may face other major psychological issues (Ayaz?Alkaya 2019). Social isolation also enhances these psychological problems and elevate mental health issues as they tend to stay at a place rather than visiting or moving to other places.
This is a case study of a 34-year-old man Thomas Wailerhas, who has been experiencing persistent episodes of loose stools and diarrhoea and a lot of red bright blood as well as mucus also passing with stools accompanied by abdominal pain and fatigue. The diagnosis made was Ulcerative Colitis. Ulcerative colitis is one kind of inflammatory bowel disease (IBD) which results in inflammation as well as sores or (ulcers) in the digestive tract.
The pathology, list of medication such as corticosteroids, immune suppressive drug has been discussed in the study and blood test, colonoscopy and histological interpretation has been done which all indicated about Ulcerative Colitis. The complication which has been found are Arthritis, liver illness, ocular inflammation, severe dehydration, risk of severely bleeding, colon cancer as well as osteoporosis that the patient might need to be aware of. In such condition, patient must adhere to the treatment suggested by the doctor which might improve their life quality and help them to avoid further complications.