My husband gets blood in stool for a couple of years with no finding in colonoscopy. Please help.

Hello,

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The description you provide coincides with obscure overt GI (gastrointestinal) bleeding which means overt bleeding and having an obscure cause. Since he already had an endoscopy and colonoscopy and which were unremarkable, then he might have small intestinal bleeding. This can easily be missed on endoscopy, colonoscopy and in fact, time CT (computerized tomography) scans are unable to detect it. The approach as per guidelines is to repeat the gastroscopy or colonoscopy given the predominant symptoms of the patients. For example, if some have upper abdominal pain, or lower abdominal pain, or discomfort should repeat the testing with the respective given symptoms. The reason is that the endoscopist sometime can miss an obvious abnormality in the colon or stomach when they are not prepared enough, or performed in a situation of emergency. So the yield of detection after a second repeat examination before jumping to expensive testing is always recommended and often rewarding. So I suggest you discuss this thing with your endoscopist. The second investigation in the row is capsule endoscopy which can detect the hidden occult causes in the small bowel. But this has to be done in a controlled setup and the test is somewhat expensive as well. You did not share his age, plus any symptoms related to abdomen besides bleeding may help us to figure out the likely potential cause underlying his problem. You can share the images or complete colonoscopy and endoscopy reports with me, plus any blood test that he had recently or in the last three years which would help to understand his condition fully. There is a long list of disorders that can cause obscure overt bleeding in the GI tract namely angiodysplasia, Dieulafoy's lesion, telangiectasia, Meckel diverticulum, small bowel tumor, and Heyde's syndrome.

Hello,

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Thanks for providing much insight into his symptoms and reports (attachment removed to protect patient identity). I have reviewed all the blood reports and the endoscopic pictures. But at this moment, I am unable to see the radiological images that you shared. Plus I would need that you should provide me colonoscopy report, gastroscopy report, CT scan report, and lastly histopathology report from gastroscopy and colonoscopy. All in translation, please. Since you already mentioned that he was found to have chronic ulcerative colitis (UC) on colonoscopy with the involvement of the rectum and left colon and his response to Solafalk. I think that he had Solafalk-responsive left-side colitis. Since he has been taking Solafalk when he underwent colonoscopy, there is still that we can appreciate microscopic activity on biopsy. And that is why I want to see those histopathological reports to conclude that he has UC and not other colitis-like infections. I am afraid that he should be using Solafalk for regular use, for the rest of his life. Since Solafalk is an anti-inflammatory drug and works only when used. If stopped, then he is deemed to recur the disease. For prevention of the frequency of recurrence, he might need low-dose immunosuppressive medications like Azathioprine or 6 Mercaptopurine. His doctor might have discussed this with you. Since his colitis immediately responds to Solafalk I do not think that we need to give him any steroids because the role of steroids and Ssolafalk is similar i.e. to bring remission to an acute flare of active colitis. I have seen that his Amylase is 200 plus, has he been given Azathioprine or 6 Mercaptopurine before? Pancreatitis with increased amylase is one of the common side effects of Azathioprine. I would need to check for occult TB, hepatitis B, and infection before starting him on Azathioprine. Please find the below investigations.

Hello,

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It is fine if the reports will take time to be available. Meanwhile, he should continue taking Solafalk (Mesalazine) if already taking. Or if he is not currently on any medication, he should start taking tablet Asacol (Mesalamine) 400 mg two tablets thrice daily, which means a total of 6 tablets equal to 2.4 gm of Mesalamine in a day. Since you mentioned and as far as I understand that he has some disease activity in the left side of colon, and not only limited to the rectum. In a condition, where disease activity only involves rectum, Enams can be preferred. I also believe he will be happy to use oral medications since it is less cumbersome than a rectal enema.

I will be waiting to hear from you again. And also how your husband feels about my plan of action considering his problem.

Hello,

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I have reviewed the reports (attachment removed to protect the patient's identity). But I can not see a CT scan report in translation. But that is fine if there is no abnormality on the CT scan you need not share. You are right about his anxiety regarding the long-life use of these medications, but I must tell you these Solafalk and others in the group namely Asacol, which I previously suggested usually work in the bowel and do not get absorbed in the blood to cause side effects. That is why this medication can be used for years before any side effects develop. I was more in favor of oral tablets of Asacol (Mesalamine) 800 mg thrice daily. Since your husband has disease activity in the transverse colon and unfortunately these enemas of Solafalk work up to most distal portions of the large bowel namely the rectum, sigmoid colon, and left side of the colon. I suggest that he can discuss this with his treating physician. Lately, I also asked for the start of immunosuppressive medications. But if he is not comfortable then at least he should not think of stopping Solafalk or Asacol (if he starts). Unfortunately, he has to remain on at least one of these medications to keep his ulcerative colitis in remission. Well, sushi is seafood, and it can cause certain bugs within the bowel, but this bug does not long that much longer. If it was an infection with certain bugs acquired via sushi, it should have resolved within three weeks or so without any antibiotics. Pariet is fine but the acidity is not a side effect nor a result of ulcerative colitis. Again they are safe medications and can be used for a longer duration.

Thank you.

Hello,

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This is absolutely my pleasure. I am humbled to listen to your courteous and generous remarks as always. The CT scan report is not attached yet. You can add later on when you follow up after your husband's acknowledgment and once he gives his response on the plan of action which we have discussed. Stay happy and stay safe.

Thank you.

Hello,

Welcome back to icliniq.com.

Well, I have had no experience with Mastiha. I think that is probably a plant derivative (herbal medicines I guess). I absolutely agree that he should take a chance with diet, but to be very honest, given his histology report and evidence of chronic active ulcerative colitis in the large bowel; would be least to provide any benefit in the long term. You probably know that ulcerative colitis is remitting relapsing disease, so at times the disease can go into remission, and patients often confuse that the diet ( in the absence of medicines) has caused remission. But after some time (variable) the disease recur with the start of bleeding in stools and abdominal pain. So this was my concern, which was in favor of continuing him on Solafalk at least for regular use. If it were allergic colitis (eosinophilic colitis or food allergy), the dietary modifications would have been the best step to start with. I want to know if he can get a simple stool Calprotectin level, and show it to me. This will tell if the disease is in remission at the moment.

Hello,

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Thank you once again. Yeah sure, keep me posted. I surely understand his concern and would look forward to tailoring the treatment plan according to his wishes.

Thank you.