IBD

Question 1

An anxious 40 year old lawyer complaining of dyschezia. His surgeon diagnosed the case as anal fissure and referred the patient for colonoscopy before anal fissurectomy operation. The colonoscopy was unremarkable except for aphthous ulcers in the terminal ileum beside the anal fissure.
The surgeon was asking, can I proceed with surgery?

Answer 1

*Hold surgery temporarily until further evaluation (e.g., biopsies from ulcers, MRI pelvis if needed, inflammatory markers like CRP, fecal calprotectin) to assess for Crohn’s disease.
*The presence of aphthous ulcers in the terminal ileum raises the possibility of early Crohn’s disease, even though the colonoscopy was otherwise unremarkable.

Question 2

What are the possible causes of these ileal aphthous ulcers?

Answer 2

1. Early Crohn’s disease (most important and likely).
2. Non-specific ulcers (e.g., due to NSAID use, which is common for pain relief in fissures).
3. Infectious causes (e.g., viral infections like CMV, especially if immunocompromised).
4. Drug-induced ulcers (e.g., medications like NSAIDs).
5. Ischemic injury (less likely in terminal ileum without systemic vascular issues).
6. Other inflammatory conditions (like Behçet’s disease, though rare).

Question 3

How to manage this case?

Answer 3

1-Further evaluation:
*Histopathology: Biopsy of the aphthous ulcers to check for granulomas (Crohn’s indicator).
*Blood tests: CBC, CRP, ESR to check for systemic inflammation.
*Fecal calprotectin
*Imaging: MRI pelvis to assess perianal disease if Crohn’s suspected.
2. If Crohn’s disease is confirmed
Start medical therapy (5-ASA agents, corticosteroids, or biologics like anti-TNF depending on severity).
*Surgery would need to be adapted: fissurectomy can still be done cautiously but with awareness of poor healing risks; sometimes seton placement or minimally invasive measures are preferred.

Question 4

A 22 year old woman presents with a 6-month history of diarrhea, right iliac fossa pain
and weight loss. Blood tests show her platelet count is 721 × 109/L, haemoglobin 100 g/L
and C-reactive protein (CRP) 62 mg/L. Investigation reveals a diagnosis of terminal ileal
Crohn’s disease and her symptoms improve with a course of oral prednisolone.

Answer 4

A-What is the next most appropriate treatment?
Following the induction of remission with oral prednisolone, the next step is maintenance therapy to prevent relapse in Crohn’s disease. The most appropriate treatment would be:
Azathioprine or mercaptopurine (thiopurines) – immunosuppressive agents used for maintenance of remission.
Alternatively, methotrexate can be used in some patients, particularly if thiopurines are not tolerated.
Anti-TNF agents (e.g., infliximab, adalimumab) may be considered if there are poor prognostic features or if there’s a failure to respond to immunomodulators.
B- She asked you about her plan to get pregnant, what is your advice and treatment
*The best time to conceive is when the disease is in remission, as active disease can increase the risk of complications (miscarriage, preterm birth, low birth weight).
*Azathioprine and mercaptopurine are considered safe in pregnancy and can be continued.
*Methotrexate is contraindicated in pregnancy and must be stopped at least 3–6 months before conception.
*Biologics (e.g., infliximab, adalimumab) are generally safe during pregnancy, especially in the first and second trimesters.