Diagnosis: Ulcerative colitis (Montreal E2, left-sided), diagnosed 2013, initially presenting as left-sided proctosigmoiditis; initially well controlled on oral and rectal 5-ASA therapy.1

IBD Phenotype: Ulcerative colitis, Montreal extent E2 (left-sided); no documented extension beyond this extent; no ileostomy or pouch.2

Active Medications:
1. Infliximab (Remicade) 600 mg IV every 4 weeks (dose optimized); pre-medications given prior to infusion (diphenhydramine 25 mg IV, acetaminophen 500–1000 mg PO, hydrocortisone 100 mg IV); started 2017-08-09.3
2. Mezavant (mesalamine) 1.2 g, 2 tablets PO BID; started 2013.4

IBD-Related Surgeries / Hospitalizations:
- 2017-08-09: Hospitalization for ulcerative colitis flare — Mayo 2 disease to splenic flexure on flexible sigmoidoscopy; treated with IV steroids and infliximab (Remicade) with excellent in-hospital response.5
- 2017-10-11: Emergency department visit for UC complication — bright red blood per rectum/melena for 1 week with mild cramping, shortly after starting Remicade and tapering off prednisone; discharged home with return precautions and outpatient follow-up.5
- 2017-11-26 to 2017-11-30: Hospitalization for UC flare despite Remicade therapy — increased stool frequency, abdominal cramping, tenesmus, intermittent bloody stools; colonoscopy 2017-11-27 showed Mayo 1 at the splenic flexure and Mayo 2 from 35 cm to the rectum; treated with Remicade 600 mg IV and IV solumedrol 20 mg BID, changed to prednisone 2017-11-29, tapered as outpatient.5

Past surgical history: none recorded; no IBD-related intestinal resections, ostomy, or perianal surgical procedures documented.5

Past Medical History:
- 2023: Internal hemorrhoids, grade 1-2 — noted on colonoscopy 2023-08-22; hemorrhoid banding deferred due to concurrent anal fissure.6
- 2023: Inflammatory anorectal polyp at 6 cm and inflammatory pseudopolyps — anorectal polyp biopsied August 2023; pseudopolyps noted on 2023-08-22 colonoscopy.7
- 2025: Anal fissure — developed during course of Pentasa enema use; treated with topical nifedipine cream and diltiazem 2% ointment twice daily for 3 months.4
- 2022: Chronic arthralgia — reviewed by rheumatologist and presumed osteoarthritis.8
- 2023: Dermatitis — diagnosed by dermatologist; prior pruritic rash on arms, back, and abdomen queried as possible folliculitis vs psoriatic-type skin reaction possibly related to infliximab.9
- 2019: Dental history — prior root canal and cracked tooth with remote infection; odontogenic infection in 2024 requiring an extended period of antibiotics, during which infliximab was held for 3 months.10

Prior IBD Therapies:
- 2025-05 to 2025-06: Entocort (budesonide) 0.02 mg/mL enema 1 PR daily x 14 days; ongoing as of the 2025-05-25 visit.4
- 2024-10 to 2024-11: Pentasa (mesalamine) enema course given after colonoscopy showing Mayo 2 rectosigmoid disease; stopped after ≤2 weeks due to developing anal fissures; partial symptomatic improvement (less urgency, less mucus, less blood in the stools).4
- 2024-09 to present: Mezavant (mesalamine) 1.2 g EC tablets, 2 tablets PO BID, resumed (had not been taking it) per 2024-09-18 telephone visit; ongoing as of the 2025-05-25 visit.4
- 2024-02 to 2025-05: Pentasa (mesalamine) 1 g suppository PR daily (recommended 2024-02-25 for mild proctitis; later 1 suppository q3days PRN, then 1 QD x 30 days at the 2025-05-25 visit); ongoing as of the 2025-05-25 visit.11
- 2023-09 to 2024: Cortiment (budesonide MR) 9 mg PO daily; inadequate response (no significant improvement after 2.5 weeks); off Cortiment for a few months as of approximately September 2024.12
- 2019 to 2020: Pentasa (mesalamine) 4 g/100 mL enema 1 PR QHS x 30 days, used as needed for occasional urgency/rectal bleeding; ongoing at the 2019-06-09 and 2020-07-19 visits.10
- 2017-11-27 to present: Infliximab (Remicade) 600 mg IV (10 mg/kg) every 4 weeks maintenance, dose optimized after November 2017 Mayo 2 disease (one 2024-11-18 procedure note records REMICADE 300 mg IV q60days as dose optimized); initial responder — clinical and endoscopic remission documented (2020-01-20 colonoscopy Mayo 0 throughout with pathology showing quiescent IBD; 2020-07-19 assessment of deep clinical and endoscopic remission); subsequent secondary loss of response — symptomatic exacerbation in February 2021 with interval increased to every 4 weeks; interval extended to every 6 weeks in February 2022 with a subsequent flare, then returned to every 4 weeks; therapy interrupted 2024-03-27 to 2024-07-12 for an odontogenic infection (approximately 2 months on Mezavant and Cortiment instead), resumed 2024-07-12 with pre-medications added to avoid infusion reactions; persistently/moderately active disease despite optimized infliximab (2024-11-18 colonoscopy Mayo 2 rectosigmoid); record notes she has never obtained complete clinical remission while on infliximab; switch to vedolizumab (Entyvio) or the EXIGEM trial discussed in 2025 (patient interested, not yet started, wished to complete dental work first); ongoing as of 2025-08-17.13
- 2017-08 to 2017-10: Infliximab (Remicade) 5 mg/kg IV induction started during hospitalization for UC flare (Mayo 2 to splenic flexure on sigmoidoscopy) with IV steroids; good initial in-hospital response; steroid-dependent — symptoms recurred as oral prednisone tapered (prednisone finished 2017-10-11); received an extra Remicade 5 mg/kg dose with persistent symptoms; plan at the 2017-10-22 visit to increase Remicade to every 4 weeks for breakthrough symptoms; last dose 2017-10-31.14
- 2017-11-30 onward: Salofalk (mesalamine) 1 g suppository PR BID, discharged on this with Salofalk 4 g enema QHS and Cortifoam 10% 1 application QAM; continued long-term ('continue salofalk suppositories' per the 2023-09-25 plan); to present.15
- 2015-09-23: Salofalk (mesalamine) 1 suppository PR daily x 1 month added to Mezavant 4.8 g PO daily and Cortifoam 1 PR daily (oral + rectal 5-ASA combination); ongoing as of that visit.1
- 2015-09: Cortifoam (hydrocortisone 10% rectal foam) 1 PR daily started approximately 2 weeks before the 2015-09-23 visit; partial response (more solid stool, less blood, more energy); continued until symptoms resolve.1
- 2013 to 2015: Topical rectal 5-ASA therapy added early due to persistent symptoms and inflammation; November 2015 scope showed Mayo 2 proctitis to 15 cm; continued on topical 5-ASA.16
- 2013 to 2017: Mezavant (mesalamine) oral 5-ASA started at UC diagnosis (later 6.5 g PO daily); responder — rapid clinical remission on 5-ASA with endoscopic remission maintained 2013–2015 (March 2015 office sigmoidoscopy on Mezavant showed no rectal inflammation); dose reduced to 2.4 g PO daily in August 2015 (with aspirin started) associated with flare (4-5 stools/day, nocturnal bleeding, mucus), then re-escalated to 4.8 g PO daily approximately 2 weeks before the 2015-09-23 visit with substantial clinical improvement.1

Social History: Non-smoker, non-drinker. Works at a workplace involving lifting heavy objects; attributes lower back pain to lifting heavy objects at work. Married; was caring for her husband while he was COVID-19 positive (2021).8

Family History: Sister with ulcerative colitis.2

Endoscopy History:
- 2024-11-18 Colonoscopy: Very mild Mayo 2 colitis with scattered erosions and loss of vascularity in the distal 25 cm (rectum and sigmoid Mayo 2; ascending, transverse, and descending Mayo 0), slightly worse than on prior endoscopy; terminal ileum documented; complications none.17
- 2023-08-22 Colonoscopy: Terminal ileum normal; ascending and transverse Mayo 0; descending, sigmoid, and rectum Mayo 1 (loss of vascularity and erythema, mild, mostly inactive); internal hemorrhoids and inflammatory pseudopolyps; on retroflexion, linear ulcers passing through the dentate line more consistent with prolapse than ulcerative proctitis; prolapse-like changes in the rectum.7
- 2022-11-25 Colonoscopy: Terminal ileum normal; ascending, descending, and sigmoid Mayo 1 (erythema, decreased vascular pattern, mild friability); transverse Mayo 0; rectum Mayo 1 (patchy colitis); anorectal ulcers felt to be related to prolapse rather than active UC.5
- 2020-01-20 Colonoscopy: Terminal ileum and entire colon normal (Mayo 0 throughout, no active disease); one internal skin tag on digital rectal examination; no complications; clinical and endoscopic remission.13
- Sigmoidoscopy (date not stated, reported in a 2018-05-27 note): Mayo 2 disease to the splenic flexure and likely beyond.8
- 2017-11-27 Colonoscopy: Terminal ileum normal; cecum to distal transverse colon normal; 5 cm of Mayo 1 disease at the splenic flexure (40 cm); continuous Mayo 2 disease with erythema, friability, decreased vascular pattern, and small scattered erosions from 35 cm to the rectum; active ulcerative colitis to the splenic flexure.18
- 2017-08 Flexible sigmoidoscopy: Mayo 2 disease extending to the splenic flexure (disease previously limited to sigmoid and rectum at 2015 diagnosis).19
- November 2015 Repeat scope: Mayo 2 proctitis to 15 cm.16
- March 2015 Office sigmoidoscopy: No evidence of rectal inflammation on 6.5 g of Mezavant.1
- Flexible sigmoidoscopy (between November 2023 and February 2024): Minor grade 1-2 hemorrhoids; findings concordant with MRI defecography showing no internal or external rectal prolapse; anorectal ulcers felt related to prolapse rather than active UC.20
- Colonoscopy (date not stated, referenced in a letter dated 2025-02-27): Grade 1-2 haemorrhoidal prolapse.6

Pathology:
- 2024-12-01, colon biopsies (2024-11-18 colonoscopy), UC dysplasia surveillance: Ascending, transverse, and proximal descending colon — normal, negative for dysplasia; distal descending and proximal sigmoid — mild architectural distortion, negative for dysplasia; mid/distal sigmoid and rectum — mild chronic active proctocolitis, negative for dysplasia.17
- 2023-08-22, colonoscopy biopsies: Cecum, ascending, transverse, and descending colon — normal; rectum — quiescent chronic colitis; anorectal polyp at 6 cm — inflammatory.21
- 2020-01-20, colon biopsies (cecum, ascending, transverse, descending, sigmoid colon, and rectum): Large bowel mucosa with architectural distortion, consistent with quiescent IBD; no evidence of dysplasia.13
- 2017-11-27, colonoscopy biopsies (UC flare on Remicade, rule out CMV): Terminal ileum, right colon, and transverse colon — without significant abnormality; colon at 40 cm — focal chronic active colitis, negative for dysplasia, no viral inclusions; colon at 35 cm — chronic colitis with moderate activity, negative for dysplasia, no viral inclusions; rectum — chronic proctitis with severe activity and ulceration, negative for dysplasia, no viral inclusions; no cytomegaloviral inclusions on H&E, with CMV immunohistochemistry to be performed as a precaution (no addendum result available).22

Imaging:
- MRI defecography (date not stated; discussed in letter dated 2024-02-11): No evidence of internal or external rectal prolapse; concordant with flexible sigmoidoscopy findings.20
- Limited bowel ultrasound (prior to the 2024-09-25 IBD follow-up; date not stated): Slightly thickened sigmoid colon with no increase in vascularity.23
- 2017-11-26 Abdominal x-ray: Featureless left colon with stool loading.24