Abdominal Crohn’s Disease
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Abdominal Crohn’s Disease
Benign Disease- You are asked to evaluate a 32-year-old woman who reports bloating, abdominal pain, and incomplete evacuation. She underwent restorative total proctocolectomy/ileal pouch anal anastomosis (IPAA) with S-pouch 4 years ago for chronic ulcerative colitis (UC). Computed tomography (CT) of the abdomen and pelvis with oral and intravenous (IV) contrast did not show any evidence of small bowel obstruction. Pouchoscopy was without evidence for inflammation. Contrast pouchogram showed a 7-cm long conduit connecting the pouch to the anus. What is the most likely 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 25-year-old man with ulcerative colitis (UC) is 2 years status post restorative proctocolectomy with J-pouch. He was doing well until 5 weeks ago, when he developed moderate pelvic abdominal pain and a significant increase in the frequency of his bowel movements (>10/day). Dietary changes did not improve the symptoms. Pouchoscopy revealed moderate severity diffuse erythema and friability, with exudates and erosions. Stool cultures are negative for any growth. The best next step in treatment for this patient is
- 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 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 15-year-old patient with 3-year history of Crohn’s disease presents with abdominal pain, nausea, and vomiting. Which of the following modalities is recommended to evaluate for small bowel disease?
- 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?
- A 55-year-old man presents with abdominal pain and rectal bleeding. He has a 20-year history of Crohn’s proctocolitis and has perianal disease. He was treated with infliximab for 5 years but developed anti–tumor necrosis factor (TNF) antibodies. He had an allergic reaction to adalimumab. He has been on usketinumab for the past year with minimal improvement. You drained two prior perirectal abscesses and placed setons in the past 2 years. He currently has minimal complaints from the indwelling setons. A recent colonoscopy confirmed the persistence of chronic active proctosigmoiditis without evidence of dysplasia on multiple biopsies. He reports signficant disruption of his life and work and "wants this disease controlled, even if it means an ostomy." On physical examination, the abdominal is soft and minimally tender. Anorectal examination shows a well-controlled transphincteric fistula with seton without evidence of sepsis. Which of the following surgical options is most appropriate for this patient?
- A 34-year-old otherwise healthy woman, who underwent total abdominal colectomy with end ileostomy 1 year ago for fulminant Crohn’s disease colitis, presents to the office with ongoing bloody mucoid discharge per rectum and tenesmus. On examination, her abdomen is unremarkable with end ileostomy. Ileostomy is healthy and pouches well. Rectal examination is remarkable for normal perineal skin, normal tone, and absence of fistula and fissure. She has been through four different biologics. Endoscopy shows deep ulcers in the rectum with mucosal friability. She has bothersome mucoid anal discharge multiple times per day and wishes to know whether this can be resolved. Her small bowel disease was previously active and is now quiescent on entyvio. What is the best next option in her management?
- A 45-year-old patient presents to the emergency department with diarrhea and abdominal cramping 48 hours after eating raw oysters. Which is the most likely cause?
- A 42-year-old previously healthy woman presents to the emergency department with 2 weeks of right lower quadrant abdominal pain and diarrhea. Computed tomography (CT) of the abdomen and pelvis shows terminal ileitis and associated enlarged mesenteric lymph nodes. Serologic testing for which of the following should be performed?
Venous Thromboembolism Treatment and Prophylaxis After Surgery for IBD- A 44-year-old woman with Crohn’s disease presents with severe abdominal pain. She was previously on infliximab but has been asymptomatic off therapy for 15 years. She is admitted to the hospital with terminal ileal Crohn’s disease and has persistent symptoms despite inpatient medical therapy. Risk factors for VTE development in this patient include:
- A 35-year-old man undergoes an urgent ileocolic resection for medically refractory Crohn’s disease. He presents to the ER two weeks post-operatively with nausea, abdominal bloating and constipation. He has not been compliant with his extended LMWH prophylaxis due to cost. He is hemodynamically stable with normal laboratory evaluation. You recommend:
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 65-year-old man presents with abdominal pain, 15-lb (6.8-kg) weight loss, rectal bleeding, diarrhea, and joint pain. He had recently started taking prednisone for rheumatoid arthritis. On endoscopy, he is noted to have mucosal friability and ulcerations with pseudopolyps in the descending colon with rectal sparing. His terminal ileum is normal. Which finding is associated with a diagnosis of Crohn’s disease?
- 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 45-year-old man with history of ulcerative colitis presents for endoscopic assessment of his J-pouch after experiencing occasional bleeding, urgency, and abdominal pain for the past 3 months. He does not smoke or use nonsteroidal anti-inflammatory drugs; he was unresponsive to antibiotics and topical mesalamine preparations. Endoscopic images of the pouch and prepouch ileum are shown (Figures 1 and 2). What is the most likely histologic finding from the biopsies?
- 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 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 28-year-old woman with a 12-year history of Crohn’s disease presents with cramping abdominal pain, a 15-lb (6.8-kg) unintentional weight loss, and recurrent emesis. She has been taking infliximab maintenance therapy for the last 4 years. Magnetic resonance enterography demonstrates multiple short strictures over a 15-cm portion of the mid-jejunum with decompressed distal small bowel. Colonoscopy shows no active perianal or colonic disease. What is the best definitive treatment?
- A 50-year-old man with a history of ulcerative colitis presents for follow-up 6 months after emergent total abdominal colectomy with end ileostomy. He complains of pain and persistent drainage from the perianal area. Ileoscopy is normal. The pathology report from his surgical specimen demonstrates full-thickness inflammation and granulomas. What is the most appropriate next step?
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- Anorectal Disease
- A 34-year-old man has a constant, “dull ache” of the lower rectum accompanied by intermittent spontaneous rectal discharge. Imaging reveals a supralevator abscess with direct extension through the levators to the ischiorectal fossa. What is the next step in treatment?
- 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 52-year-old woman presents with a distal recurrent rectovaginal fistula after 2 failed endorectal advancement flap repairs. She had normal findings on colonoscopy and endorectal ultrasonography confirmed a rectovaginal fistula in the very distal rectum with an intact sphincter complex and seton in place. What is the best next surgical treatment?
- An obese 45-year-old man presents for follow-up after undergoing a bedside incision and drainage of a recurrent left ischiorectal abscess. On examination, you observe a draining left ischiorectal surgical site as well as a right ischiorectal skin punctum that has been draining for several months. What is the most likely underlying cause?
- About ASCRS Textbook of Colon and Rectal Surgery
- Medical Therapy for Crohn’s Disease
- Infectious Colitides
- Anorectal Disease
- A 55-year-old patient presents with fever, pelvic pain, and painful bowel movements. On examination, she is found to have an anal fistula without induration or perirectal abscess. Her white blood cell count is 29,000. After fluid resuscitation and broad-spectrum antibiotics, vital signs return to normal. Magentic resonance imaging (MRI) of the pelvis is obtained (media). What is the best next step in her management?
- A 34-year-old male who engages in anal receptive intercourse presents to the clinic with a 2-week history of rectal pain, bright red bleeding, tenesmus, and persistent diarrhea. He has family history of Crohn’s disease. Urgent colonoscopy reveals normal ileum and colon but moderate proctitis with patchy ulcerations and copious amounts of mucus. Rectal cultures and biopsy results are pending. The most appropriate next step in management is
- Rectovaginal Fistula
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Minimally invasive stapling in the deep pelvis- Malignancy
- A 50-year-old woman was found to have a right colon adenocarcinoma on screening colonoscopy. The tumor shows a loss of MMR function. Her family history is significant for uterine and pancreatic cancer. The rest of the imaging is negative for metastatic disease. What is the most appropriate next step in treatment?
- A 48-year-old postmenopausal female with no family history of colon cancer is diagnosed with a cecal adenocarcinoma. Staging reveals no evidence of metastatic disease. What is the next best step in management?
- Perioperative
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