Case Presentations #2 Saturday November 13, Case #1 HPI 11/14/10. Uma Mahadevan-Velayos MD. Complicated Crohn s Pregnancy

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1 Case Presentations #2 Saturday November 13, 2010 Uma Mahadevan-Velayos MD Case #1 Complicated Crohn s Pregnancy HPI 34 yo F with Crohn s disease presents to office 18 weeks pregnant, moved back to SF from Ky Symptomatic for years, presented with obstruction in 1996 and had emergent subtotal colectomy. Since then multiple surgeries for perianal disease No response to 5ASA, antibiotics, episodic infliximab therapy In remission on azathioprine 1

2 PMH: Crohn s PSH: Subtotal colectomy 1996, fistulectomy 1998, laparoscopy 1999, abscess 2003, 2008 Allergies: Phenergan Medications: PNV, Folate, Prozac SH: no tobacco, married, advertising FH: no IBD, MGF with CRC Colonoscopy 2002 (UCSF) Ileo-sigmoid anastomosis in the distal sigmoid, at around 25 cm. The ileum was mostly normal for 100 cm from anal verge Just proximal to transition from colon to small bowel, the small bowel mucosa was slightly edematous and erythematous. Path: active enteritis The colorectal remnant was normal from about 10 cm to 25 cm. A stricture was found in the anal canal and rectum (5 cm) Path: Chronic acitive proctitis The narrowing would permit passage of index finger and scope. At least one fistula opening could be identified. 8/2009 Similar. Periodic dilation of stricture performed by GI in Ky Developed mononucleosis 11/09. Azathioprine stopped in 1/10 due to low WBC Inadvertent pregnancy so remained off azathioprine On presentation to office, having 2 BM per day without obstructive type symptoms PE: unremarkable. Inactive perianal disease Labs normal 2

3 Wants to know what to do now? Would you add medications? Would you scope her? Any specific recommendations for OB? Patient was advised to continue as she was and follow up with us closely. If symptoms worsened can consider addition of anti-tnf such as certolizumab Recommended high-risk OB and scheduled cesarean section On F/U patient continued to do well Delivery Term intrauterine pregnancy 41+ weeks Admitted 10/8/2010 painful early labor C-section 10/10/2010 for arrest of descent and chorioamnionitis Given cefoxitin and erythromycin Male infant, Apgar 3, gm. Moderate meconium 24 hours after C section given regular diet. Developed diarrhea and abdominal distention BM per day GI Consult called on 10/13/2010 3

4 What should we do now? Is this a Crohn s flare? Is this post-operative? What tests would you want to see? Diagnostic Tests Patient found to be C. dificile positive Started on IV metronidazole by OB CT scan: Dilated small bowel throughout the abdomen and pelvis with numerous air-fluid levels, extending just beyond the distal ileorectal suture line. extreme rectum is decompressed with mild wall thickening which raises the possibility of obstruction from rectal/perianal inflammation. CT Scan 4

5 What would you do now? What medicine would you give for C. Dif? Is this Crohn s, Post-operative or C. dif? What else would you recommend? Does she need a colonoscopy? Patient improved on oral vancomycin. Distention improved slightly but patient was passing gas and stool and was able to eat. KUB 10/19 (9 days post-op) Multiple dilated loops of bowel, at least some of which are small bowel measuring up to 6.5 cm, concerning for small bowel obstruction. Patient is eating and passing gas and stool (4-5 BM per day). Narcotics reduced Patient discharged home on 2 weeks of oral vancomycin 2 weeks later, she calls stating she is feeling much better Distention improved by 60% 2-3 soft/liquid stools, no vomiting However poor appetite, still with upper abdominal distention Labs: WBC 11.4, HCT 32.8, Albumin 2.7, ESR >100, CRP 240 (10/13 401) 5

6 C. dificile checked again (1 week after stopping abx): Positive Is this too soon to recheck? Patient restarted on oral vancomycin with long taper Scheduled for colonoscopy Safety of medications Drug FDA Category Breastfeeding Metronidazole B? Depends on dose: crosses Vancomycin C Probably safe Hydrocodone C Safety unknwon Case #2 Ulcerative Colitis and Dysplasia 6

7 HPI 67 M with UC flare USOH until 6/2009 when developed LLQ pain and CT showed diverticulosis Colonoscopy: 6/09 showed 2.5 cm multilobulated friable mass in rectum. Removed endoscopically: TVA with adenocarcinoma-insitu. Normal colonic mucosa Repeat Flex sig with no residual tissue 7/09, 10/09 Hemorrhoidal banding 10/09: developed bleeding Repeat Flex sig: showed inflammation in rectum and sigmoid consistent with UC Did banding lead to UC? How unusual is this presentation of UC? Started on HC enema, mild improvement Given mesalamine 2.4 gm Oral budesonide (?) 1/5/2010 Flex sig Acute and Chronic inflammation to transverse colon Presents to UCSF for further management Lost 30 lbs/30 days BM daily with blood Cough: on avelox. CXR negative. PPD + started on INH 1/28/2010 PMH: Aortic aneurysm with repair, Barrett s, GERD, Hypothyroid FH: no CRC or IBD SHX: Works as a funeral director, smoked for 15 years in past, 1 PPD Meds: PPI, levothyroxine, lipitor, mesalamine 2.4 gm, INH, Asa 81 mg, Allergies: Ibuprofen (anaphylaxis) PE: thin, otherwise unremarkable Labs: Hgb 9.7, Albumin 3.1, CRP 23, 7

8 67 M with new diagnosis of UC 10/09 and history of adenocarcinoma in-situ in rectal polyp PPD positive on INH Having a severe UC flare Medical therapy versus Surgical Therapy? His AIS was prior to diagnosis of UC; was he at higher risk or was this sporadic? Started on prednisone 40 mg daily After 30 days of INH can start infliximab Discussed surgical resection Patient improved dramatically on prednisone therapy Flex Sig 3/2/10: moderate to severe colitis Flex Sig: 30 cm 8

9 CT Scan Infliximab started 3/7/10 (2 doses given) Patient worsened with steroid taper Colonoscopy 3/30/2010 Severe pancolitis. Normal ileum Path: Mod-severe chronic active colitis. No fungus What would you do now? Rescue therapy? Surgical therapy? Does history of adenocarcinoma in situ effect type of surgery? 9

10 4/2/2010: subtotal colectomy 8/19/10: completion proctectomy Path: no evidence of malignancy Patient doing great. Gained weight, back to work, feels wonderful Case #3 Refractory Pouchitis HPI 54 M UC s/p IPAA referred for pouchitis 1973: Bloody diarrhea amebiasis (?), metronidazole. Did well for 2 years. Recurrent bloody diarrhea, dx with UC. Developed worsening diarrhea with SAS, Asacol Maintained on cortenema, intermittent oral steroids for 15 years Two stage IPAA in 1989 at UCSF 10

11 Lost 40 lbs post-op, recurrent diarrhea Diagnosed with pouchitis Responded to mnzl. Multiple courses over yrs Developed diffuse tendinitis with cipro and peripheral neuropathy with mnzl Also bouts of SBO since surgery Prior to his visit at UCSF 2003 On amoxicillin/clav and clarithromycin BM per day, diet dependent, occ.blood Weight stable; chronic LLQ pain PMH/PSH: B/l knee surgery Shx: married, 3 sons, MD, no tobacco Fhx: mother UC, Mat Uncle Crohn s, 1 st and 3 rd son with ileal Crohn s, 2 nd son with UC/PSC PE: unremarkable Pouchoscopy Rectum Ileum Pouch 11

12 SBFT What would you do now? What is his diagnosis? What role does his family history play? What are his medical and surgical options? Pathology: Ileum: minimally active chronic inflammation. No granulomas or dysplasia Pouch: minimally active chronic inflammation SBFT normal Started on oral budesonide 9 mg daily Some response, started on 6MP Responded, but with breakthrough bouts of pouchitis, treated with antibiotics 12

13 Pouchoscopy: 2005 Pouchoscopy: 2008 ileum Ileum Pouch Patient was started on certolizumab 6 months ago. Initially, possible response, but then no difference despite split dosing and continuing 6mp 100 mg 12 BM per day, LLQ pain Started on prednisone 40 mg daily. Tapered down to 20 mg and felt better 13

14 Pouchoscopy 2010 rectum Ileum pouch Pathology 8/2010: chronic active inflammation (ileum, pouch) 2/2008: normal duodenum, stomach Chronic active ileitis, acute inflammation in ileum What would you do know? What is his diagnosis? Current meds: CZP 200 q 2 wks, 6mp 50 mg, prednisone 20 Would you make a medication change? Would you offer him surgery? 14

15 Patient opted to switch to adalimumab with antibiotics for breakthrough symptoms Repeat Flex sig scheduled 15