Female patient, 55 years old with no morbid history except for ulcerative colitis diagnosed in 1994.
She initially consulted for months of evolution of abdominal pain and liquid stools with mucus.
The presence of a continuous inflammatory compromise of the rectum with a friable mucosa and small erosions covered by fibrin (Mayo 2 Endoscopic Index) was observed in the affected area.
Biopsies showed signs of acute inflammation (criptive and cryptiform abscesses) and chronic inflammation, reflected as structural alterations of the crypts (decrease in size and branching of the glands associated with necrosis).
The patient began treatment with oral manifestations (3 g/day) and rectal symptoms (with a count of 500 mg/night), with clinical and endoscopic remission (mucosal cure) (colonoscopy 2007, May Endoscopic Subindex).
Subsequently, she abandoned treatment and control, remaining asymptomatic until August 2015 when she consulted for presenting abdominal discomfort associated with liquid stools once to twice a day without blood or mucus for a month.
He did not report general malaise, fever, weight loss, abdominal and/or joint pain.
No history of smoking, food transgression or use of drugs (specifically nonsteroidal anti-inflammatory drugs, antibiotics, proton pump inhibitors, hormones or antidepressants).
Laboratory tests included complete blood count, ESR, CRP and liver profile, all normal.
In addition, serology for celiac disease was requested with negative anti-transglutaminase antibodies and immunoglobulin A in normal values.
Total erosions were performed in which only minimal and nonspecific rectal erosions were observed.
Staggered biopsies of ileum, colon and rectum separated were taken which were consistent with LC diagnosis given the presence of > 40 lymphocytes/100 epithelial cells in samples obtained from transverse colon to rectum.
In addition, alterations compatible with UC (mild distortion of glandular architecture, crypt and microabscesses exclusively) were described in the sigmoid and rectum.
Treatment with budesonide 9 mg/day was initiated, showing a favorable response at one week of treatment with a progressive decrease of the drug until discontinuation at the third month.
After 6 months of follow-up the patient remained asymptomatic (clinical remission) and in control with fecal calprotectin within normal range.
