Medical Therapy for Crohn’s Disease
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Benign Disease- A 31-year-old male patient with a history of Crohn’s disease presents to the emergency department with fever and weakness. He has four loose nonbloody bowel movements per day. Initial labs show white blood count of 1.4 × 109/L, hemoglobin of 6.2 g/dL, and platelet count of 61,000. He reports his medications were recently changed to immunomodulators in order to wean off his steroids. What testing will be most useful in making a diagnosis?
- A 36-year-old patient with ulcerative colitis (UC) underwent total proctocolectomy with ileal pouch anal anastomosis (IPAA) 3 years ago. The patient presents now with lower abdominal discomfort that is associated with bloody loose stools. Endoscopy shows erythematous friable rectal cuff with deep ulcers. The rest of the pouch appears normal. What is the most appropriate treatment?
- A 54-year-old man with a history of inflammatory bowel disease (IBD) has a 3-stage total proctocolectomy with ileal pouch-anal anastomosis (IPAA) 9 years prior. He notes that there was a long delay between his second and third stage surgery. He has had significant diarrhea, fecal incontinence, and pelvic pain for years despite multiple medical therapies, including ciprofloxacin, steroid enemas, and rifaximin. He says he has never had good pouch function. What is the most likely cause of his current clinical condition?
- A 58-year-old male nonsmoking patient underwent an ileocolic resection for Crohn’s disease with a fibrostenotic stricture. Following surgery, the patient opted to not receive medical therapy for Crohn’s disease. Six months following surgery, a surveillance colonoscopy reveals a Rutgeerts score of i3 lesions. The patient reports mild, daily right-sided abdominal pain. Which of the following is the most appropriate next step for the management of this patient?
- A 32-year-old female patient with Crohn’s disease presents with anal pain. She takes infliximab. On examination, there are large skin tags with an anal fistula draining pus and a 3 x 3 cm area of localized induration and fluctuance. The best next step in her management is
- A 43-year-old woman presents to the emergency room with 24 hours of nausea, vomiting, and bloating. She has history of Crohn’s disease with no prior surgery and is currently not taking any medications. She smokes one pack of cigarettes per day. Computed tomography (CT) is obtained (see figure below). Magnetic resonance enterography (MRE) shows mucosal edema and hyperenhancement. She is treated with intravenous (IV) fluid resuscitation, bowel rest, and nasogastric decompression. Inpatient colonoscopy performed 4 days later demonstrates inflamed ileal mucosa and narrowed lumen. What is the best next step in this patient’s management?
- A 23-year-old woman with a longstanding history of fistulizing Crohn’s disease reports diarrhea and abdominal pain. Computed tomography (CT) enterography shows an ileosigmoid fistula. After medical optimization, the fistula persists. Sigmoid colon mucosa is unremarkable on colonoscpy. What is the best next step in management?