Case 18 A flare-up of ulcerative colitis

Jenny was diagnosed with ulcerative colitis, localized to the rectum when she was aged 32. She was initially followed up in the gastroenterology clinic but after two years was discharged to her general practitioner. She managed her relatively mild symptoms with intermittent use of mesalazine 1g enemas.

At the age of 37 she gave up smoking and experienced a flare up of her symptoms. She consulted Dr Jones about the problem. Dr Jones noted a two-week history of worsening diarrhoea and abdominal pain. She noted that abdominal examination was normal.

What would you do now?

Dr Jones suggested stopping the mesalazine enemas and using prednisolone retention enemas 20 mg once daily instead. She advised Jenny to return if the symptoms did not settle.

Ten days later Jenny returned. Dr Jones recorded that the symptoms were no better. She started oral mesalazine slow release 400 mg and loperamide 4 mg each three times daily. She told Jenny to return if the symptoms did not settle.

What would be your differential diagnosis and how would you discriminate between them?

One week later Jenny requested a home visit. One of Dr Jones’ colleagues visited her at home, noted that she was opening her bowels 12 times daily, had a temperature of 38 °C and was dehydrated with a resting pulse of 112 bpm and a blood pressure of 100/60 mmHg. Jenny was admitted to hospital and two days later underwent a total colectomy for a toxic megacolon.

Jenny brought a claim against Dr Jones alleging that her assessment was inadequate and that a competent general practitioner would have treated her symptoms more aggressively initially and sought urgent specialist opinion if the symptoms failed to settle.

Do you think her claim will succeed?

Expert comment

Delayed diagnosis of toxic megacolon in a patient with ulcerative colitis is a regular allegation in medico-legal cases. It may occur with an initial presentation of ulcerative colitis (Case 8) or occur, and fail to be recognized, in a patient with known ulcerative colitis.

It is relatively common for general practitioners to have to manage conditions that are usually managed in specialist clinics. The patient may have been discharged from specialist care (as in this case) or it may be that the patient cannot contact the specialist clinic or merely seeks advice about the condition closer to home.

Ulcerative colitis affects about 1 in 1000 of the population so most general practitioners will have a few patients with the condition. However, it is an example of a condition that is usually managed in specialist clinics. If a general practitioner decides to intervene and manage the patient it is necessary to be competent to do so. It may be that the general practitioner has quite a lot of experience of the condition or the general practitioner may seek information from the sources such as the BNF, review articles in journals or other authoritative online medical resources.

In this case there were various problems with Dr Jones’s management.

There is a well-established system for categorizing the severity of a flare up of ulcerative colitis. This has been outlined in review articles in the BMJ (Collins & Rhodes, 2006) and is detailed in online UK resources such as Prodigy and the CKS database. This is outlined in Case Box 18.1.

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