Cases/Gastroenterology

Ulcerative Colitis Whose Flare Is Not Settling — Free SCA Practice Case

Woman with ulcerative colitis whose flare is not settling

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12:00

Golden Minute

Initial Introduction

•Introduce yourself

•Ask an open question — "How can I help you today?"

•Listen — don't interrupt

•Catch early cues

Data Gathering

History, ICE & Diagnosis

Clinical Management

Diagnosis, Plan & Decisions

Safety Net

Follow-up & Close

12:00

Golden Minute

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Materials for Candidate

Please review before starting the consultation

Patient Profile

Full Name

Rhiannon Bassey

Age

34 years

Consultation Type

Telephone

Age

Situation

Telephone Consultation. Same day call.

Reason for Encounter

"Colitis flare for over a week, opening bowels a lot with blood. Asking for a call today please, has something important tomorrow."

Medical Records

●PMH: Ulcerative colitis, diagnosed age 27, under the hospital inflammatory bowel disease (IBD) team. One flare 3 years ago, treated with oral prednisolone.
●Medications: Mesalazine 800 mg modified release, three tablets once daily. Etonogestrel implant.
●Allergies: NKDA.
●Social: Non smoker.

Recent Notes and Results

●IBD clinic letter, 7 months ago: Faecal calprotectin 42 micrograms/g.
●Bloods then: Haemoglobin 131 g/L, CRP 3 mg/L, albumin 42 g/L.

Patient Script

For the friend playing the patient role

Character Overview: You are Rhiannon Bassey, a 34 year old assistant manager at a garden centre, where you have worked for eight years. You live with your partner Dewi, a self employed carpenter, in a terraced house. You have no children. You have had ulcerative colitis since you were 27. It has been quiet apart from one flare three years ago, which settled on steroid tablets, and you have never been in hospital with it.

This flare started nine days ago and has got worse every day. Tomorrow at ten o'clock you have an interview for the store manager job at a much bigger garden centre across the county, with a short presentation. You have taken leave to prepare and are calling from your kitchen table, near the toilet. You left a message on the IBD nurse advice line on Monday morning and nobody has called back. Yesterday you bought some diarrhoea capsules from the chemist.

You are organised and decisive, the person at work everyone brings their problems to. You have the next twenty four hours planned to the minute and want a fix that fits the plan. You sound a little hurried. You answer plainly, but you do not volunteer your temperature, what your watch says about your heart, the dizzy spell, the antibiotics for your hand or exactly what you took from the chemist unless the doctor asks. You do not think of yourself as ill enough for hospital, because you are still up and working.

Opening Sentence: "Hi, thanks for ringing back. My colitis has gone really bad this week and my usual tablets aren't touching it, and the stuff from the chemist hasn't helped either. I've got a job interview tomorrow morning, so I really need something to calm it down by then. What can I take?"

History if Asked (Data Gathering Phase)

●When it started and how it has changed: "About nine days ago. At first three or four times a day, a bit looser than normal, and it's got worse every day. When I'm well it's once a day."
●How many times a day (if asked to count): "Yesterday it was eight times altogether, and three of those were in the night. Today I've been five times already and it's not even eleven o'clock."
●Blood, urgency and pain (if asked): "Blood every time now. Sometimes it's more blood and slime than anything else, and there've been clots. When I need to go, I have to go right then. There's a griping ache low down that builds until I've been, then settles."
●Temperature (if asked about fever, feeling hot or shivery): "I've been hot and shivery on and off since yesterday. I used the ear thermometer this morning about seven and it said 38.1. I took two paracetamol after that."
●Heart rate (if asked about her pulse, palpitations or her heart racing): "My heart's been thumping. My watch says about 105 just sitting here. It's normally in the sixties."
●Dizziness (if asked about feeling faint or light headed): "When I stood up off the toilet this morning everything went a bit grey and I had to sit straight back down for a minute. That's the only time."
●Eating, drinking, urine and weight (if asked): "I'm drinking water and squash, but I'm hardly eating, just a bit of toast. My wee is darker and I'm not going as often. I'm about two kilos down on last week."
●What she has taken (if asked about medicines, painkillers or anything from the chemist): "I bought some diarrhoea capsules from the chemist yesterday. I took two in the morning and one in the afternoon. They didn't help, so none today. Paracetamol for the cramps, that's all. No ibuprofen."
●Recent antibiotics (if asked about antibiotics, recent illness or recent visits to a doctor): "Oh, actually, yes. My sister's cat bit my hand when I was staying with her in Cardiff, about four weeks ago. It went red and puffy, so the walk in centre there gave me a week of antibiotics. Co amoxiclav, I think. My hand's fine now."
●Infection contacts, food and travel (if asked): "Nobody else at home is ill. I haven't been abroad, and I can't think of anything dodgy I've eaten."
●Mesalazine and the IBD team (if asked): "Three tablets every morning with breakfast. I never miss them. I left a message on the IBD nurse line on Monday and nobody's rung me back."
●Previous flares (if asked): "Only one, three years ago. Steroid tablets for about two months, and it settled."

Ideas, Concerns, Expectations

Gating note: Rhiannon does not raise any of the following herself. Each part comes out only when the doctor asks what she thinks is going on, what is worrying her, or what she was hoping for.

●Ideas: She thinks this is a worse version of her last flare, and that because she is still up and working on her slides she cannot be ill enough for hospital. She has not connected the antibiotics with it. If asked: "Same as last time, only worse. I'm still up and doing my slides, so it can't be hospital bad. Hospital's for people who can't get out of bed."
●Concerns: The interview. The manager there is retiring and a job like that rarely comes up in her area; it would mean more money and running her own site. If asked: "This is the job I've been working towards for years. If I miss tomorrow, I think that's it." If the doctor explores further, her voice drops: "And if I'm honest, there's a woman in an online colitis group I'm in who went into hospital with a flare and came out with a bag. I keep thinking about that."
●Expectations: Something to stop the diarrhoea for tomorrow morning. If asked: "Something stronger than the chemist ones, so I'm not running to the loo in the middle of my presentation."

If Asked: Medical History and Medications

Gating note: Rhiannon answers each of these plainly when the doctor asks about it.

●Contraception and pregnancy: "I've got the implant in my arm. My last period was about three weeks ago. I'm not pregnant."
●Other medicines, allergies and family history: "Nothing else regular. No allergies. My dad has type 2 diabetes, but nobody has bowel problems."

Social History and Lifestyle Impact

Gating note: Rhiannon mentions this naturally as the conversation turns to her work and home, not as a speech.

●Home and work: She lives with Dewi, who is fitting a kitchen ten minutes away today and could come home if she needed him. The interview is at ten tomorrow, forty minutes' drive away: a panel and a ten minute presentation. The new employer does not know she has colitis. She normally drives herself.
●Lifestyle impact: "I've hardly left the house since the weekend in case I get caught short."
●Smoking and alcohol: "Never smoked. I hardly drink, nothing this week."

If Asked: Associated Symptoms

Gating note: Rhiannon answers briefly and naturally, in one or two sentences.

●If asked about a swollen tummy, constant or severe pain, or vomiting: "No, it's not swollen and it comes and goes with the cramps. I've felt a bit sick, but I haven't been sick."
●If asked about joints, eyes, skin, mouth, chest pain, breathlessness, leg swelling or burning when passing urine: "No, nothing like that."
●If asked about mood or stress: "Stressed about tomorrow, but I'm not down. I just want to get through it."

Responses to Management (The Negotiation Phase)

●
If the doctor offers a stronger anti diarrhoeal medicine, codeine or steroid tablets to take at home:
- ●Reaction: Pleased. "Perfect, that's exactly what I need. Can I start today?"
●
If the doctor advises her to stop the chemist capsules:
- ●Reaction: Surprised. "Really? I thought that's what they were for. Are they bad for me?" She accepts once the reason is explained.
●
If the doctor says she needs to go to hospital today:
- ●Reaction: Shocked, then bargaining. "Today? I'm still up and working on my slides, it's not that bad. My interview's at ten tomorrow. Couldn't I go straight after it?" If the doctor explains what is different this time (the bloody stools, the night time stools, her temperature or her fast heart rate), she is quieter: "I didn't realise the temperature and my watch actually meant anything." She agrees to go in once the interview has been properly acknowledged.
●
If the doctor brushes the interview aside, or promises she will be out in time for it, or suggests contacting the new employer:
- ●Reaction: If brushed aside, hurt: "I know that. But you don't know how long I've waited for this chance." If promised she will be out in time, relieved and accepting: "Oh, okay. That's not so bad then." If the doctor suggests contacting the employer, unsure: "They don't even know I've got colitis. What would I even say?" She is open to it if told she need only say she has been admitted to hospital.
●
If the doctor talks about what happens in hospital, or when she has agreed to go in:
- ●Reaction: Anxious. "Is that how people end up having an operation? Will I end up with a bag?" She settles with an honest answer and a sense that going in now gives her the best chance.
●
If the doctor simply tells her to go to A&E, asks how she will get there, or gives only vague advice such as "call back if it gets worse":
- ●Reaction: "Do I just turn up? Will they know anything about me? Last time at the walk in centre I sat there for four hours." She is reassured if the doctor speaks to the hospital team first. On transport: "Dewi could come and get me, or I could just drive myself, it's not far." She accepts not driving: "Fair enough. I did go a bit grey this morning." On vague advice: "But what would I actually be watching for between now and getting there?"

Mark Scheme

Domain 1: Data Gathering and Diagnosis

0 / 16 indicators checked+0−0

Positive (0/8)

Negative (0/8)

Domain 2: Clinical Management and Medical Complexity

0 / 22 indicators checked+0−0

Positive (0/11)

Negative (0/11)

Domain 3: Relating to Others

0 / 14 indicators checked+0−0

Positive (0/7)

Negative (0/7)

Clinical Learning Points

The Core Dilemma and the Model Plan

●Rhiannon has established ulcerative colitis (UC) and a flare that has worsened over nine days despite maintenance mesalazine. She asks for something to stop the diarrhoea for an interview tomorrow.
●The question is not which tablet to add but whether this flare can be managed at home at all. Eight bloody stools a day, stools at night, a temperature of 38.1°C and a resting pulse of about 105 make this acute severe ulcerative colitis (ASUC), and the answer is emergency admission today.
●Model plan: recognise severity, explain it without blame, phone the on call gastroenterology or acute medical team, stop the loperamide, avoid codeine and anti inflammatory painkillers, mention the antibiotic history and stool tests, arrange a safe lift, help with the interview, answer the stoma fear honestly and call back later to confirm she has arrived.
●Also acceptable: sending her to the emergency department with a call or letter, the hospital IBD team if it can take her today, or seeing her in the surgery within the hour for observations while same day hospital assessment stays the plan.

Grading Severity Over the Phone

●The Truelove and Witts index, used by NICE guideline NG130 and the British Society of Gastroenterology (BSG) 2025 guideline, defines a severe flare as six or more bloody stools a day plus at least one sign of systemic upset: temperature above 37.8°C, pulse above 90 beats per minute, anaemia, or a raised inflammatory marker. Moderate is 4 to 6 stools with blood and no systemic upset; mild is fewer than 4 stools with little blood.
●Stool count, blood and night time stools can all be counted by phone, and many patients have a thermometer or a wearable that records heart rate. Treat a home reading that fits the picture as real, and remember that paracetamol taken after the reading may be lowering her temperature.
●NICE Clinical Knowledge Summaries (CKS) list features that need emergency admission: severe, nocturnal or bloody diarrhoea (more than 6 to 8 stools a day), fever, dehydration, tachycardia, severe abdominal pain, recent weight loss, and persistent symptoms despite optimal primary care management.
●Blood tests are not needed to make the decision. Naming the index is not required; recognising the features is.

Why Acute Severe Ulcerative Colitis Is an Emergency

●BSG 2025 describes ASUC as a potentially life threatening medical emergency. About a quarter of people with UC are admitted with a severe flare at some point. Complications include severe bleeding, toxic dilatation of the colon and perforation.
●About two thirds respond to intravenous corticosteroids; around one in five admitted have a colectomy during that admission, and delaying surgery when it is needed increases complications.
●A morning interview is not a reason to wait: every hour at home is time lost before effective treatment.

When Stepping Up at Home Is Right, and Why Not Here

●For a mild to moderate flare, NICE NG130 advises a topical plus a high dose oral aminosalicylate, then, if remission is not reached within 4 weeks, adding a time limited oral corticosteroid. A commonly used regimen is prednisolone 40 mg daily, reducing by 5 mg a week, which is what settled her last flare.
●Where admission is not needed, CKS advises checking adherence, considering Clostridioides difficile infection, seeking urgent specialist advice and considering a time limited oral corticosteroid while awaiting review.
●None of this applies to a severe flare. Oral prednisolone at home is not a substitute for intravenous steroids, monitoring and access to rescue therapy and surgery.

Infection in a Flare: Stool Tests

●BSG 2025 recommends stool culture and a C. difficile assay for anyone with new or worsening inflammatory bowel disease (IBD) symptoms, with a travel and contact history. UC is an independent risk factor for C. difficile, and infection in IBD is linked with more colectomies and higher mortality.
●CKS lists penicillin combinations such as co amoxiclav among the antibiotics more commonly associated with it. Her course from an out of area walk in centre is not in her records and only emerges if you ask about recent antibiotics.
●In hospital, stool tests are sent alongside starting intravenous steroids, and oral vancomycin is started if C. difficile is found or strongly suspected. Testing should not delay admission or steroids.

Medicines to Stop or Avoid

●Loperamide is contraindicated in active UC and in antibiotic associated colitis (British National Formulary, BNF). CKS advises against antimotility drugs unless a specialist advises them, because they can raise the risk of toxic megacolon. Tell her to take no more.
●Codeine is contraindicated in acute UC and in antibiotic associated colitis (BNF), and opioid analgesia may increase the risk of toxic megacolon, so it is not the answer for tomorrow as an anti diarrhoeal or a painkiller.
●Avoid ibuprofen and other anti inflammatory painkillers (CKS). Paracetamol is the appropriate simple analgesic and antipyretic. She should keep taking mesalazine and bring it with her; the hospital team will decide on maintenance treatment.

Arranging the Admission and Getting Her There

●The ideal route is a direct phone referral to the on call gastroenterology or acute medical team, or the local IBD unit's urgent pathway if it can take her today. Where the route is the emergency department, send a letter so she is expected. Let the IBD team know so she is not left waiting on the advice line.
●Hand over stool count and blood, home temperature and pulse, the faint spell, the antibiotic course, the loperamide, her mesalazine dose, previous steroid course and baseline bloods.
●She should not drive herself with a pulse of about 105 after a grey spell. Dewi can bring her if she is otherwise stable; an ambulance is appropriate if she feels faint or collapses. Seeing her in the surgery within the hour is reasonable if quicker, but must not become waiting for blood results or until after the interview.

What Happens in Hospital and the Stoma Question

●BSG 2025 recommends urgent bloods, stool tests, abdominal imaging and flexible sigmoidoscopy with biopsies. Treatment is high dose intravenous corticosteroid, for example methylprednisolone 30 mg every 12 hours or hydrocortisone 100 mg every 6 hours, with anticoagulant prophylaxis because ASUC raises the risk of venous thromboembolism.
●Response is assessed after about three days. NICE NG130 1.2.24 advises considering intravenous ciclosporin or surgery if there is little or no improvement within 72 hours, with infliximab as an alternative rescue drug. A gastroenterologist and colorectal surgeon manage her jointly.
●Patients who fear "a bag" deserve an honest, proportionate answer: most improve with intravenous steroids, some need a rescue medicine, and about one in five need a colectomy during that admission, usually a subtotal colectomy with an ileostomy. Starting treatment today gives the best chance of avoiding it. Avoid both false promises and unframed statistics.

Work, Safety Netting and Follow Up

●She is very unlikely to be fit for a ten o'clock interview tomorrow; say so honestly. She can ask the employer to rearrange by saying she has been admitted to hospital, without disclosing her diagnosis. Under the Equality Act 2010, UC can count as a disability where its effect is substantial and long term, and employers must consider reasonable adjustments in recruitment. Crohn's and Colitis UK publishes guidance.
●Before she reaches hospital she should call 999 for constant or rapidly worsening abdominal pain, a swollen or tight tummy (particularly if the diarrhoea suddenly slows, which can signal toxic dilatation), a sudden increase in bleeding, fainting or collapse, or drowsiness or confusion. A same day call back to confirm she has gone in is good practice with a patient who minimises.
●After discharge, review steroid side effects, bone health, vaccinations and that the IBD team has a maintenance plan.

Common Mistakes in This Station

●Accepting "going a lot" without counting bloody stools, and never asking about temperature or pulse, so the flare is graded as moderate.
●Going along with her belief that she cannot be ill enough for hospital because she is still up and working.
●Starting oral prednisolone or increasing mesalazine at home because steroids worked last time, or relying on the IBD advice line or an urgent clinic appointment.
●Agreeing that she can go in after the interview, or promising she will be out in time for it.
●Endorsing the loperamide or prescribing codeine to get her through tomorrow, or suggesting ibuprofen.
●Never asking about recent antibiotics, so C. difficile infection is missed.
●Telling her simply to go to A&E with no call or letter, or letting her drive herself.
●Brushing aside the interview, or answering the stoma question with a false promise or an alarming figure.

Mapped to the RCGP curriculum topic: Gastroenterology.

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