A 7 year old girl presented to the paediatric gastroenterology clinic at the Lagos State University Teaching Hospital (LASUTH), Ikeja with a history of prolonged diarrhoea of 10 weeks that progressed to frank haematochezia 2 weeks later. She also presented with abdominal pain weight loss of over 8 weeks duration. Stool was initially watery, not offensive or mucoid. Bowel motions were about 10 times per day. There was no vomiting, fever, jaundice, mouth ulcer or joint pains. The abdominal pain was crampy, diffusely localized to the umbilical and supra-pubic regions. It was neither aggravated nor relieved by any known factors. Pain did not radiate elsewhere nor, disturb the patient from sleep, associate with tenesmus or abdominal distension. The symptoms were however associated with a significant weight loss despite good appetite and adequate feeding. There were no associated respiratory and urinary symptoms. The past medical history was remarkable in the sense that she had initially presented to a general hospital where she was investigated and treated for dysentery with a course of metronidazole, co-trimoxazole and hyoscine bromide for 6 weeks without any appreciable improvement. There was no history or signs of past abdominal surgery. Patient is the first of three children to both monogamous parents. The parents are Nigerians and there was no history of similar illness in any member of the family.
On examination, she was afebrile, anicteric, mildly pale, weighed 19kg, not irritable or in respiratory distress, not dehydrated or had peripheral oedema. There was no peripheral lymphadenopathy, skin desquamation or skin discolorations. The mucous membranes and nails were normal. Mild tenderness was elicited in the peri-umbillical region but no palpable abdominal mass, hepatomegaly or splenomegaly. Rectal examination was painful, no palpable rectal mass. The rectum appeared to be narrowed and the examination finger was stained with frank blood.
The patient was admitted and investigated for causes of lower gastrointestinal bleeding. The investigations revealed Hb of 10g/dL, white blood cell count of 19,400/mm3 with neutrophil differential of 61%, lymphocyte-32% and monocyte-7%. The ESR was elevated to 34mm/hr and serum protein significantly reduced with hypoalbuminaemia of 21g/dL. The liver function test and electrolyte with urea were essentially normal. The stool and urine cultures yielded no growth after 48 hours of incubation. No eggs, ova or intestinal parasites were seen on stool microscopy. Patient was commenced on a high protein diet and all antibiotics discontinued for 10 days. While the symptoms persisted, barium enema was requested which showed dilatation of the sigmoid and descending colon in association with persistent narrowing of the rectum and effacement of the mucosal pattern that was replaced by thumb printing appearances (Figure1). These findings were suggestive of UC. Colonoscopy and rectal biopsy were performed later. The colonoscopy showed inflammatory changes extending from the anal opening up to the visible part of the descending colon. The bowel mucosa was erythemous and oedematous, with effaced vascular pattern. Tissue biopsy was granular and friable. The histology of the rectal tissue biopsy confirmed UC as shown in Figure