Crohn Disease

30 y/o white F presents with history of smoking presents with abdominal pain, diarrhea and intermittent bright red blood per rectum for > 3 months. Abdominal pain is not exacerbated by meals and diarrhea sometimes occurs at night. Reports fever, unintentional weight loss, fatigue, abdominal pain, and arthralgias. Family history of first degree relative with inflammatory bowel disease. Medications include oral contraceptives and daily NSAIDs use. Weight loss > 5% over 3 months, scleral erythema, aphthous stomatitis, perirectal abscess/ulcer/fistula, intravaginal fistula, and erythema nodosum on exam.

  • Labs

    • Consider fecal calprotectin to rule out disease

    • CBC shows anemia

    • Obtain CMP, ESR, CRP, urine pregnancy test

    • Obtain ferritin, TIBC, folate level, and 25-hydroxyvitamin D level

    • Obtain stool studies including clostridium toxin A and B, ova & parasites, and stool culture

    • Obtain yearly Pap smear with HPV co-testing due increased cervical cancer risk

  • Imaging/Procedures

    • Initial workup

      • Toxic presentation: obtain CT abdomen and pelvis

      • Non-toxic presentation: Refer for colonoscopy with biopsy

    • Obtain colonoscopy every 1 to 3 years after diagnosis

  • Treatment

    • Crohn flare: Start prednisone 40 mg daily and taper daily dose by 10 mg/weeks until 20 mg qd and then taper by 5 mg/week until finished

    • Immunomodulators and/or biologics

      • Initiate per GI instruction

      • Administer PCV13 and PPSV23 if started

    • Start iron, vitamin D, and B12 supplementations

    • Administer HPV vaccine

  • Referrals

    • Refer to GI

    • Perianal involvement: Refer to colorectal surgery

  • Counseling

    • Patient advised that smoking cessations reduces associated complications

    • Patient counseled that she is at higher risk for nutritional deficiencies, osteoporosis, anemia, and thromboembolic events (e.g. DVT), and malignancy

Notes

  • Smoking, OCPs, and regular NSAID use increase risk for conditions

  • Patients diagnosed at age < 30 years often suffer greater complications

  • Increased risk for cervical, biliary tract, colorectal, and skin malignancies

  • Physical exam

    • Anterior uveitis and episcleritis (scleral erythema) may be present

    • Lesions may occur at any point along the GI tract

    • Fistulas from GI tract to vagina may form

Ulcerative Colitis (UC)

Young adult with h/o recent abdominal infection presents with chronic abdominal pain. Pain associated with bloody diarrhea. ROS positive for blurred vision, arthritis. Reports diet rich in meats/fats and family h/o UC. Uveitis, aphthous stoma on exam.

  • Labs

    • Obtain CBC, ESR, CRP, FOBT, bacterial stool culture

    • Recent antibiotic use: Obtain C. difficile toxin PCR

    • Recent consumption of under-cooked beef: Obtain stool cx for E. coli O157:H7

  • Endoscopy/colonoscopy reveals contiguous inflammation limited to colonic mucosa; biopsy consistent with UC

  • Treatment: Refer to GI

    • Mesalamine

      • Disease limited to rectum: Start mesalamine 1g rectal suppository qhs

      • Extensive disease: Start mesalamine (Asacol HD) 1.6 g TID x4 weeks; continue 800 mg TID for maintenance of remission

    • Symptoms refractory to 5-ASA: Start budesonide (Uceris) 9 mg qd x8 weeks; consider adding probiotic E. coli 1917

    • Symptoms refractory to budesonide: Consider infliximab (Remicade) 5 mg/kg IV at weeks 0, 2, and 6; continue q8 weeks thereafter

    • Consider azathioprine 2 mg/kg/day for maintenance of remission

  • Counseling

    • Pt encouraged to call if experiencing fever, severe abdominal pain, 7 or more stools daily, and/or GI bleeding

    • Pt advised that cases of severe UC  (>7 stools/day and elevated ESR) will require hospital admission for treatment with IV corticosteroids and/or surgical intervention

    • Pt counseled that she is at greater risk for cervical CA and osteoporosis

    • Pt counseled that UC increases risk for colon CA and that regular colonoscopies will be started within 10 years of diagnosis

Notes

  • Risk factors for UC include family history, living at higher latitudes in Western nations, diets high in meat/fat, and recent abdominal infection

  • UC-associated complications include uveitis (4%), aphthous stomatitis (4%), and arthritis (21%)

  • Normal ESR and CRP do not r/o UC

  • Medications

    • Mesalamine suppositories are more effective than oral formulations

    • Probiotic E. coli 1917 was shown to be as effective as mesalamine for achieving symptom remission

    • Azathioprine is a mercaptopurine derivative that acts to halt DNA replication