Clinical background
Records covered three hospitals over five years: two colonoscopies with biopsies, intermittently raised faecal calprotectin, a normal MR enterography, and several courses of empirical treatment. No consolidated summary existed.
Gastroenterology · Germany
Making sense of five years of conflicting gastroenterology letters
A 34-year-old woman with abdominal pain and diarrhoea held letters variously describing irritable bowel syndrome and possible Crohn's disease, and wanted a single coherent summary of what had actually been tested.
Gastroenterology Germany Specialist report issued in 6 days
The referral question
“What has objectively been demonstrated across the available investigations, and which gaps remain in the diagnostic record?”
Anonymised clinical timeline
Dates are expressed as intervals rather than calendar dates, and identifying details have been altered, so that the sequence of care can be followed without identifying the patient.
Year 1
First presentation
Intermittent lower abdominal pain and loose stools up to four times daily, no rectal bleeding, no weight loss. Coeliac serology negative.
Year 1 + 4 months
First colonoscopy
Macroscopically normal colon and terminal ileum; segmental biopsies taken. Histology reported no granulomas and no chronic architectural distortion.
Year 2
Raised faecal calprotectin
One elevated result recorded. Not repeated after the subsequent treatment course.
Year 2 + 3 months
Empirical treatment
Course of treatment given at a second hospital; clinic letter from this episode first used the phrase 'possible Crohn's disease'.
Year 3
MR enterography
Reported as normal, with no small bowel wall thickening, no mural enhancement and no complications.
Year 4
Second colonoscopy
Performed at a third hospital. Again macroscopically normal with biopsies showing no features of chronic inflammatory bowel disease.
Year 5
Conflicting correspondence
Letters variously described irritable bowel syndrome and possible Crohn's disease; no consolidated summary existed in any record.
Year 5 + 2 months
MedReview 365 case opened
148 pages of correspondence, endoscopy and histology reports uploaded and consolidated into one indexed clinical timeline.
Year 5 + 2 months, 6 days
Specialist report issued
Reviewed by a consultant gastroenterologist with an inflammatory bowel disease practice; objective findings separated from provisional labels.
Year 5 + 4 months
Reassessment planned
Treating gastroenterologist used the consolidated timeline to plan repeat calprotectin testing and a focused reassessment.
Documents reviewed
Every item supplied by the patient was indexed before review. Nothing was assessed in isolation from the rest of the record.
148 pages of clinic and discharge correspondence (three hospitals)
Indexed by date and source to trace where each diagnostic label first appeared.
Two colonoscopy reports with photographic documentation
Extent of examination and biopsy sites recorded.
Two sets of histopathology reports
Checked specifically for granulomas, crypt architectural distortion and chronic inflammatory infiltrate.
MR enterography report
Reviewed for small bowel involvement and complications.
Faecal calprotectin results (four values)
Plotted against symptom episodes and treatment courses to assess interpretability.
Coeliac serology, full blood count, CRP, ferritin
Reviewed for objective inflammatory or nutritional markers.
Medication and treatment course history
Used to determine whether raised markers had ever been rechecked after treatment.
Questions raised for the treating team
Every report ends with a prepared question list. The questions are written to be asked of the patient's own clinician — they are prompts for discussion, not recommendations.
- Which of my results objectively demonstrate inflammation, and which are simply labels carried forward in letters?
- Where did the phrase 'possible Crohn's disease' originate in my record, and was it ever supported by tissue diagnosis?
- Should the raised faecal calprotectin results have been repeated after treatment, and should they be repeated now?
- What criteria are usually required before a diagnosis of inflammatory bowel disease is formally recorded?
- If inflammatory bowel disease is not demonstrated, what does the assessment pathway for functional symptoms look like?
- Can my treating team work from a single consolidated summary so that future letters do not conflict?
Structured report highlights
Extracts from the signed specialist report, reproduced in the same section order used in every MedReview 365 report.
Origin of the diagnostic label
- Histology from both colonoscopies reported no granulomas and no chronic architectural change.
- The 'possible Crohn's disease' label originated in a single clinic letter and was repeated in later correspondence without new supporting evidence.
Unresolved objective findings
- Two faecal calprotectin values were raised but had not been repeated after treatment, leaving their significance unresolved in the record.
- The report set out how serial calprotectin is normally interpreted alongside symptoms and endoscopic findings.
Criteria checklist
- The objective criteria usually required before inflammatory bowel disease is recorded were listed, with which had and had not been met in this record.
- No diagnosis was assigned by the reviewer.
Practical output
- A single indexed clinical timeline was supplied for the patient and, with her consent, for her treating gastroenterologist.
- Red-flag features prompting earlier review were listed, including rectal bleeding, nocturnal symptoms, fever and unintended weight loss.
What happened next
The patient's gastroenterologist used the consolidated timeline to plan repeat calprotectin testing and a focused reassessment. The second opinion clarified the record; it did not assign a diagnosis.
This case study is anonymised, published with patient consent and altered where necessary to prevent identification. It describes how one written second opinion was prepared and discussed. It is not a treatment recommendation, not a diagnosis, and not an indication of any expected result in another patient. Always discuss your care with your own treating clinician, and seek emergency care for urgent or deteriorating symptoms.