Crohn’s Disease: Surgical Management [sounds like]
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Benign Disease- A 48-year-old woman with Crohn’s disease presents to the clinic for evaluation of right lower quadrant abdominal pain. Her surgical history is significant for proctocolectomy with end ileostomy. What began as a small pustule adjacent to her ileostomy has rapidly progressed into a painful 1-cm ulcer (Figure). Physical examination demonstrates peristomal ulcerations with serpiginous, irregular, and violaceous borders. The most appropriate management for this patient is:
- A 28-year-old man with a history of ulcerative colitis undergoes a total proctocolectomy with stapled ileal pouch–anal anastomosis. Six months after surgery, he presents with urgency, increased stool frequency, and bloody bowel movements. Endoscopic examination findings are shown (Figure A and B). What is the best next step in management?
- A 23-year-old man who is being treated with infliximab for ileocolonic Crohn’s disease presents with a large left perianal abscess. Operative drainage reveals a perianal abscess and a superficial transsphincteric fistula involving the posterior anal canal at the dentate line. Inspection of the rectum reveals proctitis. What is the best next step in management?
- A 25-year-old man presents to the emergency department with worsening intermittent, colicky abdominal pain of 1 week’s duration. He has experienced several weeks of irregular bowel habits and loose stools. Examination reveals right lower quadrant tenderness without guarding or rebound; his white blood cell count is 20,000/µL (20109/L) with 80% polymorphonuclear leukocytes. Computed tomography reveals marked edema of the terminal ileum with a comb sign, a loss of fat planes, and narrowing of the lumen. The appendix is not seen. What is the best next step in management?
- You are consulted on a 43-year-old woman with Crohn’s disease, who underwent a balloon dilation procedure for an ileocolic stricture 4 months ago. She is now admitted to the hospital with complaints of right lower quadrant pain that radiates through her right lower extremity, diarrhea, and abdominal distention. Her white blood cell count is 15,000/µL (15109/L), and examination reveals right lower quadrant tenderness without peritonitis. She is currently receiving prednisone and biologic therapy for her Crohn’s disease. Imaging is shown (Figure). In addition to intravenous antibiotics, what is the most appropriate next step in management?
- A 35-year-old woman is taken to the operating room for a proctocolectomy with end ileostomy for Crohn’s disease–related colonic dysplasia. What is the most appropriate surgical management of the perineal dissection?
- Anorectal Disease
- A 32-year-old woman with a history of Crohn’s disease presents with pain of 3 days’ duration and swelling in the perianal region. Computed tomography confirms an ischiorectal abscess with transsphincteric fistula. In addition to draining the abscess, what is the best next step in management?
- A 40-year-old woman with a history of Crohn's disease presents to your office with quiescent proctitis and a 4-mm rectovaginal fistula just above the anorectal ring. There is no appreciable sphincter defect. What is your best recommendation for repair?
- A 27-year-old woman presents with a grade 4 perineal laceration 2 weeks after vaginal delivery. At the time of delivery, a repair was attempted. She presents today reporting passage of flatus and stool from the vagina. On examination under anesthesia, the patient is found to have a low rectovaginal fistula. What is the next step in management?
- A 25-year-old woman with perianal Crohn’s disease reports increased perianal pain and drainage. Over the past year, she had 4 setons placed for perianal fistulizing disease. She is receiving optimal biologic dual therapy. On examination, she has increased erythema and 4 draining setons. What is the best next step in management?
- A 45-year-old woman presents with induration and chronic draining sinuses in the perineum, axilla, and groin. She underwent a screening colonoscopy 2 years ago, the result of which was normal. What is the best long-term management strategy to prevent recurrence?
- A 28-year-old woman with perianal Crohn’s disease is referred for evaluation for perianal itching. On examination, she has large bilateral anal skin tags that are painless to palpation. What is the most appropriate treatment?
- Perioperative
- Malignancy