IBD

Question 1

A 37-year-old man was diagnosed with Crohn’s disease when he was 18 years old. He was initially treated with a course of corticosteroids with prompt relief of symptoms, then transitioned to azathioprine. He reported intermittent adherence to his thiopurine therapy and required repeated courses of corticosteroids for “flares” which he would describe as acute, severe onset of abdominal pain with inability to pass bowel movements or gas. He had several hospitalizations for acute small bowel obstructions requiring nasogastric decompression and intravenous corticosteroids. Due to recurrent bowel obstructions due to stricturing disease, he had an uneventful laparoscopic-assisted ileocolonic resection of 12 cm of strictured terminal ileum 1 year ago. He was lost to follow-up until 4 weeks ago, when he presented with complaints of chronic diarrhea, right lower quadrant abdominal pain, and fatigue. He has smoked a pack of cigarettes daily for the past 18 years and has been taking _ibuprofen several time_s daily for the past few months. His family history is notable for an older brother with Crohn’s disease who has required 3 resections for stricturing disease. Colonoscopy is performed, which revealed the images in the figure. Which of the following factors is associated with his higher risk for postoperative clinical recurrence?

A. Non-steroidal anti-inflammatory drug use

B. Family history of stricturing Crohn’s disease

C. Current smoking status

D. Corticosteroid dependence

E. Thiopurine non-response

Answer 1

• Approximately 40-50% of patients with Crohn’s disease have clinical recurrence within 5 years following resection.
• This patient clearly has both endoscopic and clinical recurrence of his ileal Crohn’s disease as evidenced by his clinical symptoms of increased stool frequency and abdominal pain as well as his endoscopic findings of large and deep ulcers in his neo-terminal ileal and diffuse ileitis.
• Risk factors for postoperative clinical recurrence include

1. penetrating disease behavior
2. shorter duration of disease prior to resection
3. multiple surgical resection history
4. smoking status, and
5. endoscopic disease activity

High-risk features of Crohn’s disease burden include age <30 years, extensive anatomic involvement, perianal or severe rectal disease present, deep ulcerations on colonoscopy, prior history of surgical resection, stricturing and/or penetrating disease behaviors. These features are associated with worsening disease severity, reflecting the cumulative impact of Crohn’s disease activity over time. The presence or absence of these features aid in the risk stratification of patients for therapeutic decision-making

Question 2

A 73-year-old man with non-small cell lung cancer has been treated with atezolimumab for the past 1 year. He is now admitted to the hospital with 1 week of 12-18 daily episodes of diarrhea. His stool has turned bloody for the past 2 days. On examination, his blood pressure is 120/80 mm Hg, pulse is regular at 75 beats per minute, and he is afebrile. On examination, he has mild diffuse tenderness to palpation on exam. His laboratory test results are normal except for a slightly elevated white blood count. Stool studies are negative for Clostridioides difficile or other infectious etiologies. The atezolimumab therapy was discontinued. A colonoscopy reveals moderate patchy pancolitis with small scattered ulcerations throughout the colon [figure]. He is started on intravenous steroids and shows no signs of improvement after 72 hours. What is the best next step in your management of this patient?

A. Discontinue steroids and manage conservatively.

B. Continue intravenous steroids for a total of 1 week before changing therapy.

C. Add 6-mercaptopurine or azathioprine to the steroid regimen.

D. Refer for colectomy.

E. Discontinue steroids and administer infliximab.

Answer 2

This patient likely has immune checkpoint inhibitor-induced colitis. Immune checkpoint inhibitors (ICIs) have changed the treatment landscape for oncology leading to durable remissions in a subset of patients and a range of potentially life-threatening inflammatory toxicities, many of which involve the GI tract. Rapid progression of ICI colitis can occur within days; thus, prompt diagnosis and treatment of this condition are required. Generally, ICI colitis responds to high-dose systemic glucocorticoids starting at doses of 0.5-2 mg/kg prednisone daily with a taper regimen over 4-6 weeks. Prednisone can be tapered once clinical improvement to grade 1 or less diarrhea is achieved. If the patient does not respond within 2-3 days, they are considered nonresponders to steroids, and escalation to biologic agents is recommended. Infliximab, a tumor necrosis factor (TNF-alpha antagonist), is effective in treating steroid-refractory immune-mediated colitis. Patients may only require 1 dose. However, the need for a second or third infusion is common. Infliximab is used to treat ICI colitis at a similar dose for IBD, starting at 5-10 mg/kg. Higher doses should be considered with low albumin levels <3 mg/dL. Vedolizumab has also been used in steroid-refractory cases. A growing body of evidence supports an early use of biologic therapy for induction.

Question 3

A 68-year-old man presents for an additional opinion regarding management of his ulcerative colitis. He was diagnosed with left-sided ulcerative colitis 3 years ago after presenting with bloody diarrhea, rectal urgency, nocturnal bowel movements, and bilateral knee pain with associated swelling. He began oral and topical mesalamine with clinical remission. He has since been maintained on oral mesalamine 4.8 grams daily. He has a history of diabetes, currently well-controlled on metformin; multiple basal cell skin cancers requiring Mohs surgery and a melanoma removed surgically with wide excision and negative margins.

He recently reported increased urgency with rectal bleeding occurring in >50% of his bowel movements without passing frank blood or clots, which are now up to 5-6 times daily. He is afebrile, and has no hemodynamic instability or abdominal pain except for slight cramping. His hemoglobin is 13.8 g/dL (normal: 14-17 g/dL), albumin 4.6 g/dL (normal: 3.5-5.5 g/dL), C-reactive protein 2.0 mg/L (normal: <5.0 mg/L), and fecal calprotectin 588 mcg/g (normal: <162.9 mcg/g). He begins budesonide 9 mg tablet daily with no change in symptoms. Repeat sigmoidoscopy is shown in figures A, B, and C. Which of the following treatments would you recommend for maintenance of remission?

B. Azathioprine

C. Budesonide

D. Vedolizumab

E. Infliximab

Answer 3

Additionally, a clinical decision support tool based on pooled data from the vedolizumab clinical trials, and a multicenter cohort study identified several features associated with greater likelihood of response to vedolizumab compared to anti-TNF agents: a) naïve to anti-TNF agents; b) higher albumin; c) disease duration >2 years; and d) moderate endoscopic activity

Question 4

26F - colonic and now perianal Crohn’s disease, you recommend combination therapy with an anti-tumor necrosis factor-α (anti-TNF) and immunomodulator. Which of the following tests would clarify her risks of immunogenicity with anti-TNF agents?

A. HLA-B27

B. HLA-DRB1

C. HLA-DQ8

D. HLA-DQA1*05

Answer 4

• A for Anti-TNF = A1*05
• young age, extensive colitis, and perianal disease place her at higher risk for disease complications and warrant steroid-sparing strategy to be initiated.
• She already has 2 risk factors for increased immunogenicity including lower albumin, higher C-reactive protein.
• HLA-DQA1*05 is a genetic allele carried by approximately 40% of Europeans identified in a genome-wide study to be associated with the development of antibodies to infliximab and adalimumab among inflammatory bowel disease patients naïve to biologic therapies. Up to 92% of infliximab monotherapy treated patients who were carriers of this allele developed antibodies at 1 year post-treatment compared to less than 10% of adalimumab monotherapy-treated patients who did not possess this allele.
• HLA B-27 is associated with spondyloarthropathies, HLA-DRB1 is associated with rheumatoid arthritis, HLA-DQ8 is associated with celiac disease.

Question 5

Tx for post operative crohns recurrence?

Risk factors with AZA?

Answer 5

1. Infliximab and azathioprine both are acceptable treatments for post-operative Crohn’s disease. However, this is a young male and also has a history of non-melanoma skin cancer.
2. AZA/thiopurine risks
   
   1. hepatosplenic T cell lymphoma
   2. non-melanomatous skin cancer

Question 6

A 45-year-old man with Crohn’s disease underwent a proctocolectomy with end ileostomy for refractory luminal and perianal disease 20 years ago. He has remained in clinical remission off all IBD-directed therapy but now presents to his gastroenterologist reporting painful nodules on his buttocks. The discomfort prevents him from sitting for prolonged periods. He also notes intermittent malodorous discharge from this region, for which he has to wear pads. The figure shows the findings on external rectal examination. He has minimal response to antibiotics. What is the best next treatment option for this patient?

A. Tacrolimus

B. Azathioprine

C. Adalimumab

D. Tofacitinib

E. Botulinum toxin injection

Answer 6

• The image shows stage III hidradenitis suppurativa (HS) with diffuse involvement of multiple interconnected sinus tracts and abscesses across the affected area.
• A systematic review and meta-analysis assessing the relationship between HS and IBD found increased odds of both Crohn’s disease and ulcerative colitis among patients with HS, especially seen in smokers.
• The initial management of moderate to severe HS usually consists of oral antibiotics (usually tetracyclines or a combination of clindamycin and rifampin).
• Alternate medical treatments include oral retinoids (in men and nonfertile women), dapsone, and TNF inhibitors adalimumab and infliximab.

Question 7

A 33-year-old woman presents to the GI clinic with a 9-month history of moderate cramping lower abdominal pain and nonbloody diarrhea up to 8 times daily, including nocturnal bowel movements and an unintentional weight loss of 25 lb, especially over the past 6 months. Notable laboratory test results include hemoglobin of 8.2 g/dL (normal: 12-16 g/dL), C-reactive protein 23.0 mg/L (normal: <10 mg/L), albumin 3.4 g/dL (normal: 3.5-5.5 g/dL), and fecal calprotectin 1,800 mcg/g (normal: <162.9 mcg/g). Ileocolonoscopy is performed and she is diagnosed with moderate to severe colonic Crohn’s disease. Representative endoscopic images are shown in figures A-E. Given the clinical and endoscopic disease activity, combination therapy is prescribed with an anti-tumor necrosis factor-α plus a thiopurine. Which of the following is associated with leukopenia in the setting of thiopurine use?

A. NOD2/CARD 15

B. NUDT15

C. ASGA IgG

D. pANCA

E. ICAM-1

Answer 7

• Genetic variations in nudix hydrolase 15 (NUDT15) have been associated with increased risks of leukopenia among thiopurine-treated inflammatory bowel disease patients. Further potentiated when combined with gene mutations in thiopurine methyltransferase (TPMT).
• NOD2/CARD15 gene mutations have been associated with ileal Crohn’s disease location

Question 8

31M w. hx of testicular cancer at age 21 treated with orchiectomy presents with a 3-year history of mild to moderate Crohn’s ileocolitis treated with intermittent ileal release budesonide. He now has 2 complex, intersphincteric perianal fistulas confirmed on MRI without abscesses. You discuss treatment options and the patient is very concerned about treatment leading to a recurrence of cancer. Which of the following options is the optimal treatment for his Crohn’s disease?

A. Infliximab

B. Vedolizumab

C. Azathioprine

Answer 8

anti-TNF DO NOT INCREASE risk of SOLIDS TUMORS including testicular cancer - only drug approved for fistulizing disease

Question 9

Which EIM of IBD is most closely related to disease activity?

A. Uveitis

B. Sacroiliitis

C. Erythema nodosum

D. Pyoderma gangrenosum

E. Primary sclerosing cholangitis

Answer 9

• EIM in IBD that paralled Dz

1. Erythema nodosum
2. Episcleritis
3. type I peripheral arthropathy (pauciarticular)

Episcleritis is the most common ocular manifestation of IBD. Vision remains normal without any changes in pupillary response to light. The cornea is not involved. Episcleritis typically parallels disease activity in IBD — treatments that reduce the activity of her colitis should improve or resolve her episcleritis. While her UC is improving clinically, she should be closely monitored for evidence of a disease flare, with as-needed dose escalation of adalimumab. This is not a case of infectious conjunctivitis — there is no reason to stop the anti-TNF. This is also not an allergic reaction — antihistamines are unnecessary. While her symptoms will likely resolve with improved UC control and time, adjunctive therapies for mild cases are artificial tears, cold compresses, and topical NSAIDs.

Question 10

45 w/ UC and IPAA for low-grade dysplasia of the colon presents for a second opinion on managing chronic pouchitis refractory to antibiotic therapy. His pouchitis developed within the first few months after the takedown of his diverting ileostomy. While he initially noted some response to courses of ciprofloxacin and metronidazole, he has had persistent symptoms of frequent diarrhea despite rotating courses of both antibiotics. A pouchoscopy is performed and shows diffuse inflammation throughout the body of the pouch and the prepouch ileum extending 20 cm above the pouch inlet. Laboratory tests are remarkable for a hemoglobin of 11.5 g/dL (normal: 14-17 g/dL), albumin 3.7 g/dL (normal: 3.5-5.5 g/dL), ALT 45 U/L (normal: 0-35 U/L), AST 40 U/L (normal: 0-35 U/L), and alkaline phosphatase 185 U/L (normal: 36-92 U/L). Stool studies are negative for enteric pathogens. Which of the following would be an appropriate next step?

A. Diverting loop ileostomy

B. MRI pelvis

C. MRCP

D. TTG IgA

Answer 10

• There are several known risk factors for pouchitis, including specific genetic polymorphisms interleukin-1 receptor antagonist and NOD2/CARD15, extensive ulcerative colitis prior to colectomy, and primary sclerosing cholangitis (PSC). PSC-associated pouchitis has a unique phenotype characterized by prepouch ileitis and often inflammation that is less responsive to antimicrobial therapy. This patient has clinical characteristics that raise suspicion for a diagnosis of PSC, including the prior history of low-grade dysplasia of the colon leading to his colectomy and his elevated alkaline phosphatase. PSC should be excluded with MRCP.

Question 11

A 19-year-old man with newly diagnosed ulcerative proctitis is studying to become a registered dieticia n. He reporting tenesmus, rectal bleeding, and frequent nighttime waking as well as a 5-lb weight loss since his endoscopic diagnosis 4 weeks ago. He would like to know your opinion regarding the use of natural products to induce and maintain remission of his disease. Which of the following supplements would you most likely recommend for him?

A. Turmeric (Curcuma longa)

B. Medical marijuana (Cannabis sativa)

C. Vitamin D

D. Fish oil

Answer 11

• Regarding use of turmeric, a pure curcumin preparation was administered in an open-label study to patients with ulcerative proctitis or Crohn’s disease; all patients with proctitis improved, with reductions in concomitant medications.
• A randomized controlled trial (RCT) of 50 mesalamine-treated patients with active mild-to-moderate UC who were given curcumin (3 g/day) showed that in 53.8% of those who received curcumin, both clinical and endoscopic remission were achieved.
• Cannabinoids suppress inflammation by downregulating the production of cytokines such as TNF-α, interferon γ, and IL-1. A RCT of 21 patients with Crohn’s disease evaluated for clinical remission (defined as Crohn’s disease activity index [CDAI] score <150) in those smoking marijuana cigarettes; unfortunately, the end point was not met, but a larger proportion of those receiving cannabis had a reduction in their CDAI score.
• Vitamin D is known to reduce levels of TNF-α, but there is limited data in IBD.
• RCTs have failed to demonstrate that fish oil is effective in maintaining remission.

Question 12

Birth control in IBD

Answer 12

• VTE risk is 2-3-fold higher in women with IBD and independently inc w OCPs
• The rise in hepatic production of serum globulins involved in the coagulation cascade (factor VII, factor X, and fibrinogen) driven by estrogen is believed to increase VTE risk.
• some evidence suggesting a 2-fold increased VTE risk in those using estrogen-based OCPs such as combination pills, the patch, or the ring. In a large Danish study with 8,010,290 women-years of observation, compared with nonusers of hormonal contraception, the risk of confirmed venous thromboembolism was not increased using progestogen-only pills or hormone-releasing intrauterine devices.
• Progestin IUDs contain levonorgestrel (LNG-IUD), are systemically absorbed at very low levels, and are approved for between 3 and 5 years.

Question 13

A 24-year-old woman with a history of Crohn’s disease of the small intestine doing well on an injectable biologic comes to see you for preconception counseling. She is in remission with no active inflammation seen on recent MR enterography and normal hemoglobin, iron level, vitamin D, and vitamin B12. What would be a common outcome for this patient with inflammatory bowel disease in pregnancy?

A. Pre-eclampsia

B. Small for gestational age

C. Cardiac congenital anomaly

D. Placental abruption

E. Developmental delay

Answer 13

• There are several pregnancy outcomes that are associated with having IBD regardless of disease activity.
• These include small for gestational age, low birth weight, and preterm birth.
• There has been no data to suggest that woman with inflammatory bowel disease are at increased risk for preeclampsia, cardiac congenital anomalies, placental abruption, or developmental delay in their offspring.

Question 14

33F evaluation and management of complex perianal fistulas in the setting of an ileal pouch anal anastomosis. The patient’s fistula initially developed just a couple months following take-down of her diverting loop ileostomy. She has had several pouchoscopies which have shown a normal-appearing pouch and prepouch ileum. CT enterography showed a normal-appearing small bowel. MRI of the pelvis was performed and revealed a long fistulous tract extending posteriorly in the midline from the ileal pouch anal anastomosis toward the coccyx with bifurcating fistula branches in a horseshoe configuration extending to both side skin surfaces of the gluteal cleft. What is the most likely cause of the patient’s presentation?

A. Crohn’s disease

B. Ischemia

C. Anastomotic leak

D. Pyoderma gangrenosum

Answer 14

• This is likely a post-surgical complication resulting from an anastomotic leak. The timing of this patient’s symptoms, less than 6 months after take-down of her diverting ileostomy and the location of the fistula extending directly off the anastomosis support this diagnosis.

Question 15

When to not use anti TNF agents?

Tofa?

Answer 15

demyelinating disorders

• transverse myelitis
• MS
• HF
• melanoma

Tofa

DVT, herpes zoster, cardic dz, elecated LDL/HDL/creatine kinase

Question 16

What arthopathy parallels IBD

Answer 16

• Parallel IBD
  
  • peripheral joint arthroapthy (Type 1 arhtropathy)- affects less than 5 large joints, such as ankles, knees, hips, and shoulders and is often asymmetrical and migratory.
    
    • In contrast, type II (polyarticular) arthropathy is frequently symmetrical arthritis involving 5 or more small joints and is not related with IBD activity - ankylosing spondylitis and sacroiliitis.
• Among the dermatologic manifestations of IBD, erythema nodosum, Sweet syndrome, and oral aphthous ulcers typically parallel disease activity
• episcleritis
  
  • CD >> UC - acute hyperemia, irritation, and tenderness.
  • Unlike uveitis, episcleritis typically parallels disease activity.

For example, mesalamines and vedolizumab are not effective for pyoderma gangrenosum. However, anti-TNF agents have some demonstrated effectiveness for PG. PG is more commonly seen in women with severe ulcerative colitis and most commonly on the lower extremities. Treatment - wound care, topical steroids, systemic steroids, and immunosuppression.

Question 17

45M Crohn’s disease of the colon on infliximab monotherapy. Doing well. What should you offer him at this visit?

A. No pneumococcal vaccines since he is immunosuppressed

B. PCV13 today followed by PPSV23 in 2-12 months

C. PPSV23 today followed by PCV13 in 2-12 months

D. Both PPSV23 and PCV13 now

Answer 17

PCV not live - safe!

Go in order!

1. If a patient has not received any pneumococcal vaccines, they should be given a dose of PCV13 followed by PPSV23 2-12 months later.
2. If the patient has received PPSV23 already, they should receive PCV13 at least 1 year after the PPSV23 is administered.

Question 18

74M w/ CHF diagnosed with ulcerative colitis 6 years ago and after failing therapy with mesalamine 4.8 g daily, he was treated with vedolizumab successfully for 5 years. He had a secondary loss of response to vedolizumab despite decreasing the dosing interval to every 4 weeks. He had a recent colonoscopy during a hospitalization for IV steroids that showed extensive disease to the hepatic flexure, some deep ulcerations, and he had no evidence of infection. He responded to steroids and now presents to your office while tapering down on prednisone and you have a discussion about therapeutic options. He made it clear that he does not feel ready for colectomy, however, he is concerned about adverse events of medical therapy. What is the best choice for next-line treatment for this patient?

A. Ustekinumab

B. Infliximab - chf

C. Tofacitinib - inc cardivasc events

Answer 18

• This older patient with UC has a number of risk factors for colectomy (extensive disease, deep ulcers, recent hospitalization with steroid use). Although colectomy is a very reasonable option for this patient, he has improved on steroids and has clearly expressed his desire to avoid surgery at this time.
• Infliximab can be used in older patients safely, but with his prior history of heart failure, it is not his safest option.
• Tofacitinib is associated with a higher rate of cardiovascular events in older patients with cardiac risk factors.
• Ustekinumab has an excellent safety profile similar to vedolizumab and is the best option for this patient.

Question 19

A 29-year-old woman with a history of open restorative proctocolectomy with ileal pouch anal anastomosis (IPAA) completed at the age of 16 has been trying to conceive for 12 months. She needed a course of ciprofloxacin for acute pouchitis 2 months ago. She is seeking preconception counseling on why she is unable to conceive. Which of the following is the most likely cause of her infertility?

A. Pelvic adhesions from IPAA surgery

B. Advanced age

C. Acute pouchitis

D. Ciprofloxacin exposure

Answer 19

• Pelvic adhesions as a result of pelvic manipulation at the time of the creation of the IPAA has been associated with a 3-fold increased risk of infertility when conducted as open surgical technique.
• Infertility, defined as an inability to achieve pregnancy in 12 months of attempting conception, increased from 15% to 48% in women post-IPAA for ulcerative colitis in a meta-analysis. A recent Cochrane analysis noted that the quality of evidence is low and better studies are needed to address the impact of IBD surgery on fertility.
• The impact of laparoscopic IPAA on fertility has not been rigorously studied. Age above 30, particularly above 35, has been shown to be associated with decreased fertility in women with or without IBD and relates primarily to the ovarian reserve.
• Active pouch inflammation and ciprofloxacin have not been shown to be associated with infertility.

Question 20

A 50-year-old man with an ileal pouch anal anastomosis is treated for idiopathic pouchitis with a 2-week course of metronidazole. He continues to experience 15 watery bowel movements daily associated with urgency and tenesmus. A pouchoscopy is performed and shows diffuse inflammation of the pouch body. The prepouch ileum is normal in appearance. Which of the following is the most likely explanation of the patient’s symptoms?

A. Small intestinal bacterial overgrowth

B. Celiac disease

C. NSAID use

D. Fructose malabsorption

Answer 20

While all of these answers are potential causes of the patient’s symptoms, NSAIDs are a very common cause of secondary pouchitis and should be considered in patients who do not respond to a course of antibiotics.

Question 21

A 70-year-old man with a history of diabetes, basal cell carcinoma removed from his hand 10 years ago, and unprovoked deep vein thrombosis (DVT) 6 months ago managed on warfarin was referred to you for management of refractory ulcerative colitis. Over the past 5 years, the patient has been on azathioprine, adalimumab, and vedolizumab. Despite full adherence and adequate trough drug concentration levels, the patient was unable to achieve clinical remission. He has abdominal pain, frequent bloody stools, and gas. He is interested in starting oral tofacitinib, especially because it is in pill form. His physical exam revealed normal vital signs. He was tender on palpation of his lower abdomen and the rest of the exam was otherwise normal. His TB test (interferon-gamma release assay test) was negative. Laboratory evaluation revealed hemoglobin 10 g/dL (normal: 14-17 g/dL), WBC 15,000/µL (normal: 4,000-10,000/µL), platelet count of 200,000/µL (normal: 150,000-350,000/µL), HBsAg negative, anti-HBs positive, and anti-HBc negative. Fecal calprotectin was 320. Colonoscopy is performed and you graded his colon as Mayo endoscopic score of 2-3. You are considering tofacitinib as an option. Which of the following would be the strongest reason to not use tofacitinib in this patient?

A. Diabetes

B. History of skin cancer

C. Hepatitis B infection

D. Deep vein thrombosis

Answer 21

Tofacitinib is a small, orally active drug that preferentially inhibits JAK-1 and JAK-3, but is active on all JAK isoforms. It was approved by the FDA in May 2018, for the treatment of adult patients with moderately to severely active ulcerative colitis.

• Patients treated with tofacitinib are at increased risk of serious infections, including active tuberculosis, invasive fungal, bacterial, or viral infections. Therefore, patients should be tested for tuberculosis and hepatitis B infection prior to starting tofacitinib. Reassuringly, this patient’s TB test (interferon-gamma release assay test) was negative and his hepatitis serology indicated that he is immunized.
• In a post-marketing safety study, an increased risk of thrombosis including pulmonary embolism, deep venous thrombosis, and arterial thrombosis was observed with the use of tofacitinib 10 mg twice daily compared to a lower dose of 5 mg twice daily or anti-TNF blocker therapy. Many of these events led to serious outcomes, including death. Therefore, tofacitinib should be used at the lowest effective dose for the shortest duration required to achieve or maintain remission. Given that the patient had a recent DVT, it would be best to avoid tofacitinib.

Question 22

A 25-year-old man with a history of ulcerative colitis undergoes stage 3 total abdominal colectomy with ileal pouch anal anastomosis for medically refractory disease. Four months after take-down of his diverting loop ileostomy, he experiences an increase in bowel movements which are small volume, and urgency, tenesmus, and blood in the stool. He undergoes a pouchoscopy. Which of the following presenting characteristics is more typical for this diagnosis as compared to pouchitis?

A. Bleeding

B. Fever

C. Tenesmus

D. Urgency

Answer 22

• Pouchitis and cuffitis can present similarly with symptoms including increased stool frequency, urgency, and tenesmus. Based on the pouchscopy, this patient has cuffitis. Rectal bleeding is more typical of cuffitis compared to pouchitis. Patients can present with both cuffitis and pouchitis and the treatment approach may be different for these conditions. Pouchoscopy is helpful in establishing the diagnosis of cuffitis or pouchitis in a patient with inflammatory symptoms.

Question 23

A 28-year-old woman presents to the hospital with a severe ulcerative colitis flare. She was diagnosed with extensive ulcerative colitis at the age of 16 and she has had progressive disease activity despite treatments with oral and topical 5-aminosalicylates, mercaptopurine, adalimumab, and vedolizumab. Upon arrival at the hospital, a colonoscopy is performed with severe colitis reported throughout the entire colon, characterized by deep ulcers, absent vascular pattern, mucosal friability present throughout the colon which also has dense areas of pseudopolyps scattered throughout the affected colon [figure]. The colon is also noted to be foreshortened with an estimated length from the rectum to the ileocecal valve of 50 cm. Which of the following endoscopic features are associated with a high risk for colectomy?

A. Absent vascular pattern

B. Diffuse pseudopolyps

C. Foreshortened colon

D. Deep ulcers

E. Mucosal friability

Answer 23

This young woman is at high-risk for colectomy based on her endoscopic findings. High-risk features for colectomy in ulcerative colitis include age <40 years, extensive disease, Mayo 3 or UCEIS ≥7, deep ulcers, low albumin, elevated C-reactive protein and hospitalization. Features of Mayo 3 disease includes both spontaneous bleeding and deep ulcerations. A UCEIS (ulcerative colitis endoscopic index of severity) score of 7 or higher is an aggregate score indicating that absent vascular pattern, mucosal friability, and deep ulcers are all present. Of the endoscopic features listed, only deep ulcers are a standalone risk factor for colectomy in ulcerative colitis. Having a foreshortened colon and pseudopolyps are indicators of prior chronic disease activity and are not associated with increased risks of colectomy or colon cancer.

Question 24

A 25-year-old woman presented to the office with severe intermittent right lower quadrant pain for the past month. She also described 5-6 loose, nonbloody bowel movements daily, increased gas and bloating over the past month. On colonoscopy, she had a normal-appearing mucosa in the colon, and only the distal 3 cm of terminal ileum was visualized. The terminal ileum had mild to moderate congestion, erythema, erosions, and friability. She had a CT enterography [figure]. What is the best next step in management?

A. Trial of rifaximin and low-FODMAP diet

B. Laparoscopic small bowel resection

C. Start biologic therapy.

D. Start prednisone taper and oral mesalamine.

Answer 24

In a newly diagnosed Crohn’s disease patient with moderate disease activity and active inflammation seen on both colonoscopy and imaging, biologic therapy should be the first-line treatment.

Question 25

A 56-year-old man with a history of pancolitis for more than 20 years underwent a surveillance colonoscopy. His father was diagnosed with colon cancer at the age of 49. A sessile lesion was found at the hepatic flexure without a clear border on 1 side [figure]. The entire lesion appeared to be removed endoscopically. Pathology showed adenomatous tissue with low-grade dysplasia (LGD) extending to the margin on 1 side. Biopsies around the lesion also showed LGD confirmed by 2 independent GI pathologists. Nontargeted biopsies from the sigmoid also showed a single focus of LGD. What is the appropriate next step in his management?

A. Repeat colonoscopy with chromoendoscopy within 3 months

B. Repeat colonoscopy with chromoendoscopy within 12 months

C. Referral to colorectal surgery for right hemicolectomy

D. Referral to colorectal surgery for colectomy with an ileoanal pouch or end ileostomy

Answer 25

• This patient had 2 areas of low-grade dysplasia. These were confirmed by 2 expert pathologists and a polypoid lesion with an indistinct border on 1 side that was not completely removed. He also had several risk factors, including pancolitis for 20 years and a family history of colon cancer in a first-degree relative at a young age.
• Therefore, the next step should be surgical referral for colectomy with ileoanal pouch or end ileostomy.
• There is no role for further surveillance, and a hemicolectomy would not adequately address his heightened risk of colon cancer.
• After colectomy with an ileoanal pouch, he should get periodic pouchoscopy to survey the pouch.

Question 26

A 58-year-old patient is admitted to the hospital with worsening abdominal pain. He has a history of Crohn’s ileocolitis and has been in remission with long-term infliximab (5 mg/kg every 8 weeks). CT enterography shows partial small bowel obstruction from distal fibrotic ileal stricture. In preparation for a small bowel resection, which of the following is most appropriate?

A. Cease infliximab use 2 weeks before surgery.

B. Cease infliximab use 4 weeks before surgery.

C. Cease infliximab use 8 weeks before surgery.

D. Continue current infliximab dose and frequency.

Answer 26

• Cessation in infliximab therapy is not required.
• Recent data with IBD undergoing intraabdominal surgery, preoperative use of anti-TNF was not an independent risk factor for postoperative infections in IBD.
• nor is it necessary to avoid primary re-anastomosis during these operations.

Question 27

A 44-year-old man with pancolitis undergoes a surveillance colonoscopy with a high-definition colonoscope. Dye spray chromoendoscopy utilizing the flushing device is planned for targeted biopsy. The prep is suboptimal with residual mucous and scattered fecal material. Although the patient feels well, there is active colitis with a Mayo score of 2 in the right colon. Which of the following is the best course of action?

A. Proceed with dye spray chromoendoscopy and targeted biopsies only.

B. Proceed with dye spray chromoendoscopy and both random and targeted biopsies.

C. Proceed with both random biopsies and targeted biopsies but no dye spray chromoendoscopy.

D. Terminate the procedure without any biopsies and reschedule with better prep.

Answer 27

• The prep is adequate for routine surveillance but not optimal to perform dye spray chromoendoscopy, which requires an excellent prep (i.e., Boston Bowel Prep score of 9). Furthermore, with mild to moderate inflammation, the yield of chromoendoscopy is decreased.
• Since the bowel prep was adequate, the best choice is to proceed with random (at least 32) biopsies from throughout the colon and targeted biopsies or removal of any visible lesions. Ideally, the surveillance colonoscopy should be done when there is endoscopic remission.

review dysplasia and IBD

Question 28

screening for osteoporosis in ibd

Answer 28

patients with IBD who have used oral corticosteroid therapy for longer than 3 consecutive months at a dose of ≥7.5 mg prednisone per day.

Question 29

A 26-year-old woman with left-sided ulcerative colitis (UC) presents to the emergency department with 3 weeks of progressively worsening bloody diarrhea and abdominal pain. A colonoscopy 3 months earlier revealed proctosigmoiditis with a Mayo endoscopic score of 1. The remainder of the colon was graded Mayo 0. An MR enterography demonstrated no small bowel inflammation. Her UC has been well controlled with oral mesalamine. On physical examination, she appears uncomfortable due to abdominal pain. She is tender in the left lower quadrant without guarding or rebound.

Laboratory testing reveals:
C-reactive protein 18 mg/L (normal: 0-10 mg/L)
Hemoglobin 8.5 g/dL (normal: 12-16 g/dL)
White blood cell count 20,4000/µL (normal: 4,000-10,000/µL)
Serum CMV antibody: 1:128
Albumin 3.3 g/dL (normal: 3.5-5.5 g/dL)
Abdominal x-ray reveals colonic thumbprinting without other significant findings.

Which of the following is the next step in the management of this patient?

A. CT scan of the abdomen and pelvis

B. Stool studies for pathogens

C. Hydromorphone PCA

D. Intravenous gancyclovir

E. Emergency flexible sigmoidoscopy

Answer 29

All patients with acute severe ulcerative colitis (ASUC) should have stool testing to rule out Clostridioides difficile infection (CDI). However, corticosteroids should not be delayed pending results of stool studies for C. difficile.Multiple studies have shown that flares of colitis complicated by C. difficile are associated with significantly worse clinical outcomes, including more extended hospital stays, higher colectomy rates, and increased mortality. If C. difficile is suspected, treatment with corticosteroids should not be withheld. However,additional treatment with oral vancomycin should be given, pending results of the stool testing, and discontinued if negative.Toxic megacolon, colonic perforation, severe refractory hemorrhage, and refractoriness to medical therapy are indications for surgery in patients with ASUC.NSAIDs, opioids, and medications with anticholinergic side effects should be avoided in ASUC. In patients with ASUC and concomitant CDI, it is recommended to treat the CDI with vancomycin instead of metronidazole. Thumbprinting is a sign of mucosal edema and in this setting, does not necessarily warrant emergency flexible sigmoidoscopy. This patient has no fever or systemic symptoms and is not immunocompromised so therefore, CMV colitis is unlikely. Treatment based on antibody results is unwarranted.

Question 30

A 65-year-old man who was diagnosed with fibrostenotic Crohn’s ileitis 20 years ago presents for the follow-up clinic visit. He had a small bowel resection of 15 cm with primary anastomosis 4 weeks ago. He is feeling well postoperatively. What is the best next step in management?

A. Start biologic therapy now.

D. Start biologic therapy as needed after endoscopic evaluation in 6 months.

Answer 30

Crohn’s patients should be risk-stratified for recurrence of the disease. High-risk patients include those with penetrating disease and active smokers. A low-risk patient, like the one presented, has longstanding, short segment, fibrostenotic disease.

low risk of recurrence- a colonoscopy should be performed around 6 months after surgery. If there is an endoscopic recurrence, then anti-TNF therapy is recommended.

Question 31

A 55-year-old man has had a history of ulcerative colitis for 25 years. He has required only 1 course of corticosteroids since the diagnosis and has remained on mesalamine therapy for many years. He has had intermittent rectal bleeding and urgency. He gets treated with dietary changes or as needed rectal mesalamine suppositories. Recently, random biopsies on surveillance colonoscopy showed low-grade dysplasia in the rectum with surrounding chronic inactive colitis. This was confirmed by a second expert GI pathologist. What is the next step in the management of this patient?

A. Repeat colonoscopy with dye spray.

C. Repeat surveillance colonoscopy in 6 months.

Answer 31

When dysplasia is found on random colonic biopsies in an IBD patient, the first step is to confirm the histologic diagnosis with an expert pathologist. If low-grade dysplasia is confirmed, the next step is to repeat colonoscopy with an enhanced imaging technique like chromoendoscopy. If the dysplastic area is visualized, then it should be resected. If the dysplastic area cannot be visualized, but repeat random biopsies show dysplasia, surgery should be discussed.

Question 32

A 78-year-old man with a previous smoking history presents with new onset of bloody diarrhea and low-grade fevers. He reports 8-10 urgent bowel movements daily, including nocturnal bowel movements. Stool studies are negative for enteric pathogens. Laboratory tests reveal a normal CRP, albumin 3.6 g/dL (normal: 3.5-5.5 g/dL), and hemoglobin 11.8 g/dL (normal: 14-17 g/dL). A colonoscopy is performed and he is found to have moderately active ulcerative colitis (graded as a Mayo endoscopic subscore 2) extending to the hepatic flexure. Which of the following factors is associated with a poor prognosis?

A. Age >70 at diagnosis

B. History of prior tobacco use

C. >6 bowel movements per day

D. Hemoglobin 11.8 g/dL

E. Extensive colitis

Answer 32

Poor prognostic factors in ulcerative colitis disease severity include age <40 years at diagnosis, extensive colitis which this patient has, severe endoscopic disease, hospitalization for colitis, elevated CRP, and low serum albumin.

Question 33

A 38-year-old woman presents to the emergency department with a severe ulcerative colitis flare. She reports more than 20 loose bowel movements daily, most with frank blood including frequent bowel movements at night, multiple incontinence episodes, and severe abdominal cramping requiring intravenous narcotics. On arrival, she is tachycardic with a heart rate of 125 bpm, hypotensive with BP 70/40, responsive to intravenous fluids but febrile with a temperature of 38.6°C. Abdominal x-ray on presentation shows left-sided mural thickening and “lead pipe” appearance. Her initial laboratory test results reveal a hemoglobin of 7.2 g/dL, albumin 2.6 g/dL, C-reactive protein 78.2 mg/L, and stool C. difficile toxin B PCR positive. She is started on intravenous corticosteroids and oral vancomycin and admitted for further management. Which of the following is a known predictor of steroid failure on day 3?

A. Hemoglobin <8 g/dL

B. Lead-pipe colon on imaging

C. >9 bowel movements/day

D. Temperature >38.3°C

E. C. difficile toxin PCR positive

Answer 33

Other features associated with steroid failure include hypoalbuminemia (<3.0 g/dL), colonic dilation on abdominal imaging, and elevated C-reactive protein (>45 mg/L).

Question 34

A 26-year-old man with extensive small bowel Crohn’s disease is admitted to the hospital with an acute flare. Over the past 3 months, he reports progressively worsening nonbloody diarrhea, now with 12-15 bowel movements daily and unintentional weight loss of 25 lb due to lack of appetite and severe abdominal cramping. He reports severe fatigue requiring frequent naps throughout the day. Upon admission to the hospital, his hemoglobin is 7.8 g/dL, iron 17 mcg/dL, TIBC 320 mcg/dL, soluble transferrin receptor 5.3 mg/L. He is given an infusion of ferric carboxymaltose. Which of the following deficiencies is associated after intravenous ferric carboxymaltose use?

A. Zinc

B. Calcium

C. Phosphorous

D. Magnesium

E. Potassium

Answer 34

Intravenous iron - clinically significant hypophosphatemia associated with severe fatigue and osteomalacia.

ferric carboxymaltose has been associated with the highest rates for hypophosphatemia. Therefore, monitoring for serum phosphorous post-IV iron infusion is an important, under-recognized step in iron deficiency anemia management

Question 35

A 42-year-old man is admitted to the hospital with acute severe ulcerative colitis. He , he appears malnourished with temporal wasting, visible pallor, and underweight BMI. A colonoscopy reveals severely active pan-colitis. He has failed multiple mechanisms of action of UC therapies and would like to proceed with colectomy. In preparation for surgery, which dietary approach would be best for this patient?

A. Oral nutrition supplements with carbohydrate loading

B. Low-FODMAP diet

C. Low-fiber diet

D. Total parenteral nutrition

Answer 35

There is evidence that patients with malnutrition may benefit from optimizing nutritional status before surgery if time permits

• reduced infectious postoperative complications.
• oral nutrition supplements with carbohydrate loading - (ERAS) recommendations

Question 36

inflammatory in nature. She has deep ulcerations in the distal rectum. She has no extraintestinal manifestations. She has never had surgery and was started on infliximab following her diagnosis. Her mother has Crohn’s colitis. Which of the following is associated with a high risk for a more aggressive disease course?

A. Ileocolonic involvement of disease

B. Age >30 at diagnosis

C. Initiation of infliximab at the time of diagnosis

D. Family history of Crohn’s disease

E. Presence of rectal ulcers

Answer 36

• Worse disease course with
  
  • diagnosed at age <30 years with extensive anatomic involvement
  • deep ulcers
  • prior surgical resection
  • stricturing and/or penetrating behavior or
  • perianal and/or severe rectal disease

This patient has deep rectal ulcers, so she is at a higher risk for a more aggressive disease course.

Question 37

A 22-year-old man with ulcerative colitis undergoes a total proctocolectomy with ileal pouch-anal anastomosis for medically refractory disease. Prior to his colectomy, he had been treated with infliximab. A level drawn prior to his last infliximab infusion was undetectable, with high antibodies. He was switched to adalimumab with no response. After surgery, he has 6 bowel movements per day with minimal urgency. Six months after his ileostomy reversal, he develops fecal urgency, nocturnal incontinence, abdominal pain, and 10 bowel movements per day. He has no known drug allergies. Pouchoscopy shows the findings in the figure. What is the best initial treatment choice for this patient?

A. Ciprofloxacin

B. Metronidazole

C. Rifaximin

D. Infliximab

Answer 37

pouchitis - tx cipro OVER flgyl

• greater symptom improvement
• better tolerated

Both ciprofloxacin and metronidazole have been shown to be effective for treatment of acute pouchitis in randomized controlled trials. However, in a head-to-head trial of ciprofloxacin and metronidazole treatment for a 2-week duration, patients on ciprofloxacin exhibited greater improvement in symptoms and endoscopic appearance compared to patients on metronidazole. Ciprofloxacin was also better tolerated than metronidazole. Rifaximin is another commonly used antibiotic for treatment of pouchitis, though the one placebo-controlled trial did not reach statistical significance. Although infliximab has been used to treat chronic pouchitis and Crohn’s disease of the pouch, this patient should not retry infliximab given a high level of antibodies which increases his risk of infusion reactions with rechallenge of infliximab.