Case Study Analysis: Ulcerative Colitis and Eleanor Brown's Health

This case study focuses on Eleanor Brown, a 48-year-old diagnosed with ulcerative colitis 17 years prior. The study details the progression of her condition, from initial diagnosis to the development of pseudopolyps and pancolitis, leading to significant weight loss and hospital admissions. It explores the structural and functional changes associated with ulcerative colitis, including mucosal damage, inflammation, and the impact on metabolic hormones and nutrient absorption. The case study also discusses the pain pathway and the mechanism of morphine in pain management, as well as the clinical manifestations of worsening ulcerative colitis, such as dehydration and hypovolemia. Furthermore, it explains the rationale behind the use of Hartman's solution for fluid and electrolyte replacement in addressing hypovolemia. The case highlights the complexities of managing chronic ulcerative colitis and the importance of addressing its various systemic effects.

Case study
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Eleanor Brown case study
Question 1
The case study describes a 48-year-old client who was diagnosed with ulcerative colitis 17
years back while she was 31 years old. This disease has been managed with a combination of
diet, medication and medical monitoring all along however it has been having periods of
remission and exacerbation which has led Eleanor to have frequent hospital admissions. The
disease has been progressing, four years back a colonoscopy was performed which revealed that
she has developed pseudopolyps and this time around her gastroenterologist requested for an
MRI which revealed that it has developed to pancolitis. The structural and functional changes of
the disease as it was progressing it led to weight loss where Eleanor reported a loss of 9
kilograms for the past two weeks prior to her hospital admission. Structurally ulcerative colitis
begins as primary lesions that are inflamed at the base of the crypts of Lieberkühn in the
rectosigmoid area of the bowel. Often the lesions affecting the mucosal areas extends laterally
causing large denuded areas. The mucosa becomes edematous, hyperemic and friable at the same
time the mucosa ulceration starts to occur as well. Destruction of the mucosa leads to bleeding,
cramping pain and urge to defecate. This is followed by chronic inflammation characterized by
narrowing and loss of the colon’s normal haustra. Finally, the pseudo polyps develop.
Pseudopolyps are masses of scar tissue normally develops from granulation tissue during the
healing phase in a repeated cycle of ulceration (Carton, 2017). Levels of some metabolic
hormones including leptin and ghrelin are associated with the chronic inflammation of the tissues
due to the structural changes as the disease progress. Hormone level alterations can affect satiety.
Appetite is reduced leading into less food consumption thus the client becomes malnutritional.
The mucosal; and intestinal bleeding due to mucosa destruction leads into nutritional losses.

When the micro and macronutrients are lost the client becomes malnutritional hence the weight
loss. Diarrhea can also lead to water weight loss (Kumpf, 2014) The pseudo polyps lead to
alterations of the intestines due to the loss of absorptive mucosal surfaces and rapid colonic
transit time. The macro and micronutrients are not given enough time a condition called
malabsorption. Lastly, client experiences symptoms including sensation of abdominal bloating,
anorexia and cramping pain. Anorexia decreases the client's appetite while the cramping pain can
be equated to the pain experienced during ingestion of food and can lead to food avoidance
rendering the patient malnutritional.
Question 2
The pain pathway involves detection of stimulus and relaying the information to the cortex
where it will consciously be perceived as pain (Uddin, 2015). The pain pathway includes; first
order neuron pathway, second order neuron and the third order neuron which is thalamocortical
tract. High-intensity stimuli activates the nociceptors. The stimuli travel through the axon of the
first order neuron which terminates in the spinal cord’s posterior horn. The spinothalamic
neurons receive the pain information and the information is relayed to the hypothalamus through
the ascending pathway of the spinal cord. The thalamocortical neurons receive the information
and pass it to the cerebral cortex. When morphine is administered it travels to the brain where it
binds the opiate receptors that is mu or kappa receptors. Which are along the pain pathway this
leads to analgesia (Kwon, Altin, Duenas & Alev, 2014). The activation of the presynaptic mu
receptors by the morphine causes the inhibition of calcium ion channel this prevents the release
of neurotransmitters. Morphine is an opioid receptor agonist, and this blocks the synaptic

transmission limiting the number of nociceptive stimuli that reaches thalamus and cortex where
conscious perception of the pain would have occurred.
Question 3
Ulcerative colitis being a long-term condition it has got clinical manifestations during its
presentation including ulcers in the colon and lesions, bloody diarrhea, weight loss, fever, and
anemia may also occur. Some more manifestations which were not there initially may present as
the disease progresses indicating that the condition is becoming progressively worse. With the
case of Eleanor 4 years back when a colonoscopy was performed it showed that she had
developed a large number of pseudopolyps. this time around when the gastroenterologist ordered
MRI it indicated that it had developed to pancolitis. The fourteen episodes of diarrhea with pus
daily for the past two weeks indicated that the condition was becoming more worse. She ended
up developing signs of dehydration which was indicated by dry, pale and cool skin with poor
turgor this was due to the excessive bloody diarrhea. The capillary refill becoming slower
accompanied by flat neck veins are indications of hypovolemia (Corley, & Barr, 2018). This
shows that the client is becoming more worse. Hypovolemia is caused by decreased circulating
fluid volume in the body tissues and in this case, it is caused by the chronic bloody diarrhea.
Question 4
The intravenous fluid that was ordered for Eleanor Brown was Hartman’s solution
amounting to 1000mls and was run for a period of 6 hours. Hartman’s solution also called
Compound Sodium Lactate is administered with 5% glucose to form solution for infusion.
Hartman’s solution with Glucose IV infusion was used to replace the lost body fluids and

electrolytes (Voldby, & Brandstrup, 2016). Due to low blood volume since Eleanor had started
showing signs of hypovolemia including flat neck veins meaning that he had decreased blood
volume in circulation. The compound sodium lactate has the following ingredients; sodium
chloride at a concentration of 6g/L, Sodium lactate 3.22g/L, Potassium chloride 0.4g/L, Calcium
Chloride Dihydrate 0.27g/L and Glucose at a concentration of 50g/L (McNab et.al 2014) The
potassium and sodium chloride both occur as colorless solutions or white crystals and are readily
soluble in water. Calcium chloride is a white crystalline powder that is hygroscopic and freely
soluble in water. Sodium lactate exists as a clear colorless but slightly syrupy solution that is
highly miscible with water. Lastly, the glucose exists as a white crystalline powder, it is
monosaccharide and freely soluble in water. The mixture of the above should be stored in a
pharmacy at a temperature not above 30 degrees Celsius.

References
Carton, J. (Ed.). (2017). Oxford Handbook of Clinical Pathology 2e. Oxford University Press.
Corley, K. T., & Barr, B. S. (2018). Shock, resuscitation, fluid and electrolyte therapy. In Equine
Pediatric Medicine, Second Edition (pp. 25-46). CRC Press.
Kwon, M., Altin, M., Duenas, H., & Alev, L. (2014). The role of descending inhibitory pathways
on chronic pain modulation and clinical implications. Pain Practice, 14(7), 656-667.
McNab, S., Ware, R. S., Neville, K. A., Choong, K., Coulthard, M. G., Duke, T., ... & Dorofaeff,
T. (2014). Isotonic versus hypotonic solutions for maintenance intravenous fluid
administration in children. Cochrane Database of Systematic Reviews, (12).
Pharmacologic management of diarrhea in patients with short bowel syndrome. Journal of
Parenteral and Enteral Nutrition, 38, 38S-44S.
Uddin, L. Q. (2015). Salience processing and insular cortical function and dysfunction. Nature
Reviews Neuroscience, 16(1), 55. Kumpf, V. J. (2014).
Voldby, A. W., & Brandstrup, B. (2016). Fluid therapy in the perioperative setting—a clinical
review. Journal of Intensive Care, 4(1), 27.