Gastroenterology Follow-Up Visit Note

Reason for Follow Up

Routine follow-up for mild-to-moderate ulcerative colitis (UC) flare and evaluation of response to oral 5-ASA therapy.

Gastrointestinal Diagnosis

1. Ulcerative proctosigmoiditis
2. Gastroesophageal reflux disease (GERD)
3. Internal hemorrhoids

Medications

1. mesalazine (Asacol®, Pentasa®) 4.8 g PO daily
2. mesalazine (Salofalk®) 1 g PR QHS
3. pantoprazole (Pantoloc®) 40 mg PO daily
4. cholecalciferol (Vitamin D3) 1,000 IU PO daily

Clinical Details

Sarah Jenkins (DOB: 14/08/1986, OHIP: 4928-310-774-AB) presents for a 6-week follow-up regarding an acute flare of ulcerative proctosigmoiditis.

She previously experienced 5–6 bloody, loose BMs/day (Bristol 6) with moderate LLQ cramping (5/10), tenesmus, and nocturnal urgency. Symptoms were aggravated by high-fiber foods and stress, partially relieved by defecation. Escalation of oral mesalazine to 4.8 g daily and addition of rectal mesalazine suppositories 6 weeks ago yielded significant improvement.

Since the last visit on 02/02/2026, BM frequency has decreased to 1–2 formed stools/day (Bristol 4) with complete resolution of hematochezia, nocturnal symptoms, and tenesmus. Mild intermittent LLQ bloating persists. Weight is stable. No fever, arthralgias, ocular symptoms, or skin lesions. GERD symptoms remain well-controlled on daily PPI.

PMHx: UC diagnosed 2021 (managed as outpatient, no prior biologic therapy or hospitalizations), GERD. PSHx: Laparoscopic appendectomy (2014) without complications. No prior bowel resections.

Investigations

Vitals: BP 118/74 mmHg, HR 68 bpm, Temp 36.7 °C, Wt 64.5 kg. Abdomen is soft, non-distended, with normal bowel sounds. Mild tenderness on deep palpation in the LLQ without rebound or guarding. No hepatomegaly, splenomegaly, or shifting dullness (no ascites).

DRE: Normal sphincter tone. Grade 1 non-thrombosed internal hemorrhoids noted. No palpable masses, fissures, or fistulae. Brown stool on glove, guaiac negative.

1. Lab results (10/03/2026): Hb 134 g/L, WBC 6.2 x 10^9/L, Plt 245 x 10^9/L, CRP 2.1 mg/L (down from 18.4 mg/L on 02/02/2026), Albumin 42 g/L, Ferritin 58 ug/L.
2. Fecal calprotectin (10/03/2026): 85 ug/g (down from 640 ug/g on 02/02/2026).
3. Stool C. difficile toxin and culture (02/02/2026): Negative.
4. Flexible sigmoidoscopy (05/02/2026): Continuouserythema, friability, and loss of vascular pattern from rectum to 25 cm (Mayo endoscopic subscore 2). Normal mucosa proximal to 25 cm. Biopsies confirmed chronic active colitis without dysplasia or CMV.

Assessment and Plan

1. Ulcerative Proctosigmoiditis

Clinical and biochemical remission achieved following 6 weeks of induction therapy with high-dose oral and topical 5-ASA, evidenced by resolution of hematochezia, normalization of bowel habits, and marked reduction in fecal calprotectin and CRP.

Differential diagnosis for residual mild LLQ bloating includes post-inflammatory irritable bowel syndrome (IBS), dietary intolerances (e.g., lactose), or low-grade residual mucosal inflammation.

• Repeat CBC, ferritin, CRP, and fecal calprotectin in 6 months to confirm sustained biochemical remission. Surveillance colonoscopy due in 2029 (8 years post-diagnosis).
• Transition to maintenance regimen: decrease mesalazine (Asacol®) to 2.4 g PO daily and taper mesalazine (Salofalk®) 1 g PR to 3 times weekly for 4 weeks, then discontinue PR therapy if asymptomatic. Discussed rare risk of 5-ASA-induced interstitial nephritis; will monitor renal function annually.
• Advised low-FODMAP trial for residual bloating, regular aerobic exercise, and continued avoidance of NSAIDs and tobacco.
• Routine follow-up in 6 months, or sooner if flare symptoms recur.
• Referred to registered dietitian for guidance on low-FODMAP diet and nutritional optimization.

2. Gastroesophageal Reflux Disease (GERD)

• Clinically stable on current PPI therapy without alarm features (no dysphagia, odynophagia, or weight loss).
• Continue pantoprazole 40 mg PO daily; trial step-down to 20 mg PO daily in 3 months if asymptomatic.
• Advised avoiding late-night meals, elevating head of bed, and limiting caffeine and alcohol intake.

Additional Notes

• Discussed the chronic, relapsing-remitting nature of UC and the importance of strict adherence to maintenance oral 5-ASA therapy to prevent flares and reduce long-term colorectal cancer risk.
• Instructed patient to contact the clinic for early review if she experiences > 3 BMs/day above baseline or recurrent rectal bleeding, and to seek urgent care for severe abdominal pain, high fever, or profuse hematochezia.
• Addressed patient's questions regarding future pregnancy planning; reassured that 5-ASA medications are safe during conception and pregnancy, and emphasized the importance of being in deep remission prior to conception.