Case: Probiotics for Ulcerative Colitis?

Arthur M. Barrie III, MD, PhD


January 20, 2017

Case Presentation

You are caring for a 45-year-old woman with a 2-year history of mild ulcerative proctosigmoiditis that began at a time of significant stress associated with the breakup of her marriage.

The patient was initially treated with oral and topical mesalamine with good response, and her colitis went into remission. She was subsequently maintained on oral mesalamine (2.4 g/day) with no relapses until 2 months ago, when she called your office complaining of a flare in the setting of increased stress.

The patient reported that she was having four loose urgent bowel movements daily, some of which were bloody, but she denied having stool leakage, incontinence, or nocturnal bowel movements. She denied having rectal or abdominal pain, fevers, or any other extraintestinal manifestations. She denied any unusual ingestions, sick contacts, travel, or nonsteroidal anti-inflammatory drug or antibiotic use prior to her flare.

For the sake of completeness, you had the patient undergo infectious stool studies, including Clostridium difficile, which were all negative. Concurrent bloodwork was reassuring, with no significant abnormality, including anemia or elevated inflammatory markers.

You proceeded to perform a diagnostic colonoscopy to re-evaluate her disease and found that she had moderately severe colitis (Mayo Score 2) with marked erythema, absent vascular pattern, friability, and erosions from the anus to the rectosigmoid colon, 20 cm from the anus. Other than a periappendiceal red patch, the remainder of her colon was normal in appearance.

After her colonoscopy, given the distal location of her disease, you prescribed the patient mesalamine enemas (4 g each evening) while continuing her oral mesalamine regimen. A 1-month follow-up clinic appointment was scheduled.

However, the patient called your office 2 weeks later and reported that she was only marginally better and that she was having difficulty using the mesalamine enemas. Your nurse suggested to the patient that instead of the enemas, she could try mesalamine suppositories or increase her oral mesalamine intake to 4.8 g/day, but the patient was reluctant to do so because of the high cost of the mesalamine products. Instead, she told your nurse that she has been researching treatment options for her colitis on the Internet and read that probiotics might be helpful; she wanted to know your thoughts.


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