1. Case Presentation

2. Female Patient AB Aged 20 First seen by me in August 2009 Had been diagnosed with Crohn’s Disease in March 2009

3. Diagnosis Initially had presented with change in bowel habit in March 09 Referred for Ix and Ileocaecal Crohn’s diagnosed after colonoscopy and biopsy MRI scan showed limited disease in ileum but diffuse colonic involvement

4. Management Initially treated with budesonide – some improvement in symptoms but suboptimal response Then tried with prednisolone – good response but unpleasant SE – weight gain and hot flushes Prednisolone gradually reduced – had a relapse so went back up on dose again

5. Management June 09 Commenced on azathioprine Not well tolerated and had admission with high temp, flu like symptoms and high WCC and platelets Admitted for Infliximab infusion August 09 Disappointing response Trial of cholestyramine – not well tolerated

6. current presentation Presented to me with one week history of increasing frequency of stools and abdominal cramps BO 8-10 x/day No blood Mucous ++ Interfering with work and quite tearful

7. What to do??

8. Examination – afebrile. Pulse 70 abdo soft. No masses. Tender RLQ. Did bloods for FBC, ESR Prescribed prednisolone and review end of week

9. Saw at end of week – bloods normal. Not taken steroids for fear of SE Symptoms unchanged

10. What to do??

11. Spoke to Dr Bebb Difficult management as not responding well to medical treatment Felt she would need surgery at some point Due to be discussed at MDT Steroids may help in meantime

12. Next seen by me in August 2010 Had a very eventful year

13. Had repeat colonoscopy October 2009 Showed minor inflammation and ulceration of the terminal ileum Referred for Surgical Management

14. Underwent laparoscopic ileocolic resection in February 2010 Complicated by post op collection treated with antibiotics Continued to have diarrhoea and abdo pain June 2010, laparatomy, resection of anastomosis and formation of ileostomy

15. Seen by me again August 2010 Pregnant and requesting termination OCP stopped due to major surgery Had been told fertility probably low SI on 2 occasions. Condom split Referred for termination Actually had missed miscarriage Commenced on Depo for contraception Awaiting reversal of ileostomy