Medical Therapy for Crohn’s Disease
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Benign Disease- A 44-year-old man with known stricturing gastroduodenal Crohn’s disease with prior dilations who is receiving maximal medical therapy is admitted for increasing upper abdominal pain, nausea, vomiting, and weight loss. On endoscopy, obstructing duodenal stricture is noted. The esophagogastroduodenoscopy scope could not traverse this area. After nasogastric decompression, his best treatment option is:
- 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 45-year-old man presents to your office with complaints of bloating, constipation, and intermittent diarrhea over the last 3 months. He has a 20-year history of Crohn’s disease and is currently receiving biologic therapy. On physical examination, he is mildly distended, without peritonitis. Colonoscopy confirms a sigmoid stricture that cannot be traversed. The most appropriate treatment is:
- A 55-year-old man presents with severe refractory ulcerative colitis. He was admitted to the hospital and placed on parenteral steroids. He is now receiving salvage therapy with infliximab, but is not responding. The best next step in management is to:
- 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 37-year-old woman with a history of ulcerative colitis underwent restorative proctocolectomy with the construction of a J-pouch ileoanal anastomosis 2 years ago. The patient presents to your clinic with tenesmus of 3 months’ duration, pelvic discomfort, and fecal urgency. Pouchoscopy reveals inflamed pouch mucosa, with normal prepouch ileum. Which medical therapy is the treatment of choice?
- An 18-year-old man with a 2-year history of Crohn’s disease treated with budesonide and 6-mercaptopurine is admitted for increased right lower quadrant pain, diarrhea, and weight loss. Computed tomography shows an ileal phlegmon. Colonoscopy shows significant deep ileal ulcers and erythema in the transverse colon. The best next step in management is:
- 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 34-year-old woman is taking mesalamine for long-standing terminal ileal Crohn’s disease and develops perirectal pain. Examination demonstrates 2 active anal fissures with waxy appearing skin tags and a partially drained perirectal abscess. What is the most appropriate treatment sequence?
- A 30-year-old woman with a history of perianal Crohn’s disease has had a seton in place for transsphincteric fistula for the past 2 months. She is also taking infliximab for medical management of her Crohn’s disease with no active proctitis seen on recent endoscopy. Ultrasonography shows 50% involvement of the sphincter complex with no undrained abscess or high blind tracts. What is the most appropriate management approach for her fistula?
- 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 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?