Medical Therapy for Crohn’s Disease
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Medical Therapy for Crohn’s Disease- Principles of Maintenance Therapy
- Key Concepts
- Postoperative Prophylaxis
- Conclusions
- References
- History
- Introduction
- Microbiome Therapies
- 5-ASA Therapy
- Corticosteroids
- Immunomodulators
- Biologic Therapy
- Antitumor Necrosis Factor Agents
- Leukocyte-Trafficking Agents
- Interleukin-12 and -23 Antagonist
- Biosimilars
- Induction and Maintenance of Remission
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 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?
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:
- 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?
- Crohn’s Disease: Surgical Management
- Introduction
- Changing Trends in the Surgical Management of Crohn’s Disease
- Indications for Surgery
- Failed Medical Therapy
- Bowel Obstruction
- Penetrating Disease: Fistula and Abscess Formation
- Toxic Colitis
- Surgical Considerations
- Overview of Operative Considerations
- Disease Recurrence Trends and Surveillance
- Special Considerations
- Anal Fissure and Anal Stenosis
- 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 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?
Management of Anorectal Abscess, Fistula-in-Ano, and Rectovaginal Fistula (2022)- Anorectal Crohn’s Disease
Abdominal Crohn’s Disease- Complications of the Pelvic Pouch
- About ASCRS Textbook of Colon and Rectal Surgery
- IBD Diagnosis and Evaluation
- Rectovaginal Fistula
- Surgical Management of Crohn's Disease (2020)
- Sexual Function After Colorectal Surgery in Women