31-Year-Old Man Successfully Treated for Colitis with Medication

Summary: A 31-year-old male patient experienced persistent lower abdominal pain and significant weight loss before seeking medical attention. After a clear diagnosis of colitis, he underwent targeted medication therapy including intravenous antibiotics and oral anti-inflammatory drugs. His symptoms improved significantly within four days, and he was discharged with a stable condition.

Case Overview:

- Age & Gender: Male, 31 years old

- Diagnosis: Colitis

- Hospital: The First Hospital of China Medical University

- Treatment Period: September 2019

- Therapy Used: Intravenous Ciprofloxacin Hydrochloride Injection, oral Mesalazine Enteric-Coated Tablets and Belladonna Tablets

- Hospitalization Duration: 4 days

- Outcome: Symptoms of abdominal pain and poor appetite resolved; condition stabilized with follow-up appointments scheduled

Initial Consultation:

The patient had previously been in good health but started experiencing mild, continuous pain in the lower left abdomen three months prior. This was accompanied by referred pain on the left side of his back. Despite losing about 3 kg in the past two weeks due to reduced appetite, he initially avoided seeking treatment. Upon examination, all vital signs were normal. He was alert and in generally good condition, though tenderness was noted in the lower left abdomen. No rebound tenderness or abnormal organ enlargement was detected. Bowel sounds were normal. Due to ongoing discomfort, he was admitted for further diagnostic evaluation.

Diagnostic Process and Treatment Plan:

After admission, comprehensive tests were conducted, including CT scans of the chest, abdomen, and pelvis, gastroscopy, colonoscopy, biochemical tests, and tumor marker analysis. Imaging revealed thickening of the colon wall, while colonoscopy showed mucosal ulcers and swelling. Although histopathological biopsy results were unremarkable, clinical findings led to a diagnosis of colitis. A treatment plan involving intravenous antibiotics and oral medications was proposed to reduce inflammation and control symptoms. The patient consented and began therapy immediately.

Positive Response to Therapy:

Four days into treatment, the patient reported a noticeable reduction in abdominal discomfort and improved appetite. There were no episodes of nausea, vomiting, diarrhea, or severe pain. He was discharged with instructions to continue oral Mesalazine and schedule follow-up blood tests after two weeks. A subsequent colonoscopy one month later showed reduced ulcer size and resolution of swelling. It was recommended that he return for check-ups every six months or seek immediate care if symptoms like diarrhea, abdominal pain, or rectal bleeding occurred.

Patient Guidance and Lifestyle Recommendations:

Before discharge, the patient was advised on essential lifestyle modifications:
- Maintain emotional well-being and manage stress effectively to prevent flare-ups
- Monitor digestive symptoms closely and seek medical help when needed
- Follow a low-residue, easily digestible diet for at least a month post-discharge, avoiding alcohol, smoking, and spicy foods

Clinical Insight:

This case highlights the importance of early detection and timely intervention in managing colitis. Young individuals, especially those experiencing persistent abdominal discomfort, should not delay seeking medical advice. Prompt diagnosis and appropriate medication can lead to favorable outcomes and prevent complications. Prioritizing health is crucial for maintaining quality of life and professional productivity.