Dear Parent,
Your son’s symptoms—altered bowel habits, right lower abdominal pain, weight loss (5 kg in 3 months), and colonoscopy findings (ileitis with distal proctitis and erosions)—are concerning for chronic inflammatory bowel disease (IBD), such as Crohn’s disease or ulcerative colitis (UC). The persistence of loose stools despite Mesacol OD and FA5 tablets suggests the need for further evaluation and possible treatment adjustment.
Key Observations:
1. Biopsy Findings (Focal Active Ileitis): Supports inflammation, common in early Crohn’s.
2.Weight Loss & Low Lipase (14 U/L): May indicate malabsorption or pancreatic involvement.
3. Distal Proctitis:Seen in UC, but patchy ileitis favors Crohn’s.
Next Steps:
- Stool Tests:Rule out infections (e.g., C. difficile, parasites).
- Blood Work:
CRP, ESR,
albumin,
vitamin levels (
B12, D) to assess inflammation/nutrition.
- imaging (MRI Enterography):Check for small bowel involvement (Crohn’s hallmark).
- Review Medications:Mesacol may need dose escalation or combination therapy (steroids/immunomodulators).
Immediate Advice:
Maintain a food diary(note triggers like dairy, gluten).
Ensure hydration/nutrition(oral supplements if needed).
Monitor symptoms closely (blood in stools, fever, worsening pain).
This requires urgent specialist care.IBD is progressive; delaying treatment risks complications (strictures, fistulas). **Consult me for a detailed plan.** For quick coordination, message on WhatsApp: **Eight Zero Zero Nine Eight Two One Three Three Two**.