Medical Management of Ulcerative Colitis
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Medical Management of Ulcerative Colitis
Benign Disease- A patient with ulcerative colitis refractory to medical therapy undergoes total proctocolectomy. Which extraintestinal manifestation is most likely to persist after the colectomy?
- 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 43-year-old man is seen on an inpatient consultation basis for ulcerative colitis that has been recalcitrant to medical management for the past 2 weeks. He has worsening abdominal pain, persistent diarrhea, rectal bleeding, and intermittent fevers. He was given empiric broad-spectrum antibiotics for elevated leukocytosis. Colonoscopy revealed pancolitis consistent with findings of ulcerative colitis. Although his pain improves, he continues to have 15 to 20 watery bowel movements per day. What is the most appropriate next step in management?
- 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 28-year-old woman presents with pan-ulcerative colitis since age 16 years. Her symptoms were previously well-controlled with vedolizumab and mesalamine, but she has recently begun to experience frequent flares of disease. She is interested in having children and is referred for consideration of elective surgery involving a restorative proctocolectomy with an ileal pouch–anal anastomosis. What is the postsurgical effect on future childbearing about which you would counsel the patient?
- A 76-year-old woman presents with a history of CHF to the hospital with abdominal pain of 24 hours’ duration and bloody diarrhea. Her temperature is 98.6°F (37.0°C), heart rate 90 beats/min, white blood cell count 16,000/mL (16´109/L), and blood pressure 110/70 mm Hg. Computed tomography imaging is ordered (Figure); Her abdomen is tender but without peritoneal signs. Colonoscopy shows patchy, superficial areas of ulceration and sloughing in the transverse colon. The best next treatment for this patient is which of the following?
- Perioperative
- Ulcerative Colitis: Surgical Management
Benign Disease- A 45-year-old man with intractable ulcerative colitis (UC) presents with a 6-month history of frequent bloody, loose bowel movements up to 15 times daily. He has significant urgency and anemia with a hemoglobin of 6.8 g/dL. He has had a 30-lb weight loss in the past 6 months, and his albumin level is 2.5 g/dL. He has been on infliximab and adalimumab in the past and is currently on vedolizumab and 40 mg/day of prednisone. What is the best next step in this patient’s management?
- A 29-year-old patient with prior history of a total colectomy and end ileostomy for fulminant ulcerative colitis presents with peristomal skin irritation and difficulty with leakage around the stoma. Painful, ulcerated purple nodules with violaceous borders are seen around the stoma site, as shown in the image below. Biopsy of the lesion shows neutrophil infiltration and perivascular lymphocytic infiltration and no infection. What is the best next step in management for this patient?
- A 45-year-old man has an 8-year history of moderate-to-severe chronic ulcerative colitis (UC), managed with biologics and with good symptom control. He has no other notable medical or surgical history. His last colonoscopy was performed 1 year ago, with random biopsies demonstrating low-grade dysplasia. The patient is concerned about the development of colorectal cancer due to his history and is here for surveillance endoscopy. What is the best next step in this patient’s management?
- A 37-year-old man with a history of ulcerative colitis (UC) presents after a recent colonoscopy. Clinically and endoscopically, he has no evidence of active disease. He has been on oral mesalamine and 10 mg of prednisone for 6 months. Attempts to wean prednisone below 10 mg result in symptoms including passing of bloody diarrhea and abdominal pain. Which of the following is the best next step in his management?
- 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 22-year-old woman with medically refractory ulcerative colitis presents for consideration of total abdominal proctocolectomy with ileal pouch-anal anastomosis (IPAA). Which of the following should be part of her preoperative evaluation?
- A 65-year-old male patient with chronic cirrhosis due to primary sclerosing cholangitis underwent a subtotal colectomy and end ileostomy for refractory ulcerative colitis (UC) 2 years ago. He presents to the emergency department for uncontrolled bleeding from his ileostomy at the mucocutaneous junction. What is the best definitive treatment for this bleeding?
- A 24-year-old man with history of ulcerative colitis (UC) is 3 days status postemergent subtotal colectomy with end ileostomy for toxic megacolon. He has a low-grade fever of 38.0 °C, rising heart rate to the 110s, rising leukocytosis to 15 x 109, and lower pelvic pain and pressure. Computed tomography (CT) of the abdomen and pelvis demonstrates abscess with fluid and gas adjacent and superior to the rectal stump staple line. How could the chance of complication have been reduced?
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