Age: 27 Gender: male
This patient has Crohn's disease in the usual location. Only 8cm of the terminal ileum is affected (20cm or less is considered limited disease). This patient responded well to Budesonide (meaning the inflammation was well treated). Because of these factors the decision was made not to start on any further medications.
Visit #1 - Initial visit to gastroenterologist office after the colonoscopy when the diagnosis of Crohn's disease was made.
Since the colonoscopy the patient's symptoms have remained the same. He has been complaining of occasional abdominal pain, diarrhea, and fatigue.
The doctor states that at the colonoscopy, 8 cm of inflammation was seen at the terminal ileum. Plan: To make sure inflammation is not present higher up in the small bowel a special CT scan has been ordered (CT enterography) For treatment Budesonide (Entocort) was given to patient. Because the effect of Budesonide could take up to 8 weeks, the follow up appointment was made in 2 months.
Visit #2 - 2 month follow-up appointment
The patient is feeling much better. His abdominal pain and diarrhea are both essentially gone. Though his energy level has improved he still feels tired more than usual.
The doctor is encouraged by how well the patient responded, but did explain that the lack of symptoms does not always mean Crohn's disease has been adequately treated. He explained this point to highlight the fact that properly treating Crohn's disease can reduce the risk of problems such as surgery. The doctor ordered a fecal calprotectin to measure the inflammation.
Visit #3 - 2 weeks later
The patient is even feeling better than the last appointment. His energy level is now back to normal and he is no longer having any symptoms The patient has 2 weeks left to take Budesonide.
The doctor calls the patient to tell him the fecal calprotectin is normal. Because this measurement suggests that indeed the Crohn's disease has been treated, the patient does not need to start on any other medications.
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