Young Male, 25, Suffers from Worsened Proctitis Due to Delayed Medical Attention
Proctitis is an inflammatory condition affecting the mucous membranes and submucosal layers of the rectum. This article presents the case of a 25-year-old male who experienced symptoms including mucopurulent bloody stools, increased bowel frequency, loose stools, and left lower abdominal pain. Upon visiting the hospital, he was diagnosed with proctitis and initially placed on fasting and nutritional support. As his condition improved, medical treatment was prioritized, ultimately leading to successful inflammation control and symptom relief.
Basic Patient Information
- Gender: Male
- Age: 25
- Diagnosis: Proctitis
- Hospital: Hegang People's Hospital
- Admission Date: June 2016
- Treatment Plan: Fasting combined with intravenous nutrition (Compound Amino Acid Injection (18AA-II), Glucose and Sodium Chloride Injection), blood transfusion, human albumin, and Mesalazine Suppository
- Duration of Treatment: 10 days of inpatient care
- Treatment Outcome: Controlled inflammation, disappearance of mucopurulent bloody stools and rectal pressure sensation
Initial Consultation
The patient, a 25-year-old male, reported experiencing mucopurulent bloody stools six months prior. Due to a busy work schedule, he ignored the symptoms. Over the past month, his bowel movements increased significantly, occurring 5–7 times daily, often with visible pus, blood, and loose stools. He also experienced a strong feeling of rectal pressure, left lower abdominal pain relieved after defecation, dizziness, fatigue, and significant weight loss that began to interfere with his daily life. Stool tests showed elevated red and white blood cell levels. A digital rectal exam revealed blood and pus on the glove. Based on these findings, he was advised to be admitted for further treatment.
Treatment Process
Upon hospitalization, additional tests were conducted. Blood tests showed significantly reduced red blood cell and hemoglobin levels, indicating the need for a blood transfusion. Biochemical tests revealed albumin levels below 28g, pointing to malnutrition and anemia. Colonoscopy results showed rectal mucosal congestion, edema, erosion, and white plaque on the surface—indicative of active ulcerative proctitis.
The patient was placed on fasting and received intravenous nutrition with Compound Amino Acid Injection (18AA-II) and Glucose Sodium Chloride solution to improve hydration and nutrition. Blood transfusion was administered to treat anemia, and human albumin was given to address hypoalbuminemia.
After two days, the patient's energy levels improved significantly, and symptoms like dizziness and fatigue decreased. Follow-up blood tests showed mild anemia and protein levels returning to near-normal. At this point, he was allowed to begin a liquid diet and was given Mesalazine suppositories for rectal inflammation.
Progress and Recovery
Following two days of blood transfusion, fasting, and supportive care, the patient's condition improved. Once stable, treatment for ulcerative proctitis continued. After approximately 10 days of hospitalization, the frequency of bloody stools decreased, bowel habits normalized, and rectal discomfort was greatly reduced. A follow-up colonoscopy showed nearly normal rectal mucosa, and the patient was discharged. He expressed high satisfaction with the treatment outcome.
Post-Treatment Care and Lifestyle Recommendations
We are pleased with the patient's improvement, but it's essential to emphasize ongoing care. He was advised to maintain a balanced lifestyle with adequate rest and sleep. Light physical activity such as walking or tai chi was encouraged, while strenuous exercise was discouraged. Emotional well-being is also crucial—family members were advised to offer emotional support and encourage a positive mindset toward recovery.
Dietary considerations were also highlighted. The patient should focus on clean, nutrient-rich, easily digestible foods such as lean meats and fish. Cold, spicy foods, and dairy products should be limited to avoid irritating the digestive tract.
Reflections on the Case
This case highlights the importance of timely medical intervention. The patient initially dismissed his symptoms due to a busy schedule and mild discomfort, allowing the condition to progress and worsen over time. By the time he sought care, he had developed anemia and malnutrition, which complicated treatment and increased medical costs. However, his adherence to medical advice and cooperation from caregivers played a key role in achieving a positive outcome. After discharge, he continued outpatient treatment as instructed, further supporting his full recovery. This case serves as a reminder that early diagnosis and treatment are vital in managing proctitis effectively.