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Challenging IBD Cases
Nancy McGreal, MDAssociate Professor of Medicine and Pediatrics
Divisions of Adult and Pediatric GastroenterologyDuke University Medical Center
Case Presentation
• 33 yo female G2P1 25 week gestation pregnancy with 3 days of sharp RLQ abd pain; no known hx of IBD
• Initially - no fevers, chills, nausea, vomiting, diarrhea
• OSH: WBC 15.8K with mild left shift, reassuring fetal US
- RUQ US – normal, no cholelithiasis or cholecystitis
- Abd MRI – no appendicitis
• Develops fever 102 F, worsening RLQ abd pain, nausea
• No contractions or leakage of fluid; good fetal movement
Case Presentation
• PMHx: endometriosis, infertility, shingles
• PSHx: T&A, ORIF arm fx, ovarian cyst removal, I&D perianal abscess 11 years prior
• Meds: Prenatal vitamin, Omega-3 fatty acid
• FHx: CAD, HTN; no IBD or colorectal cancer
• SHx: Healthcare worker, non-contributory
Case Presentation
• PE: T 100.2 F other VSS, gravid abdomen, mild tenderness in RLQ without peritoneal signs
• Work-up:- WBC 14.6K with left shift- US appendix – non-diagnostic- Abd MRI – terminal ileitis
• Diarrhea develops on day of MRI – stool cx, C. diff PCR negative
• Fevers persist to 102 F despite IV piperacillin/tazobactam
• Repeat abd MRI 3 days later shows thickened TI compatible with possible Crohn’s disease
Next Steps?
• Is this infectious ileitis vs. new onset Crohn’s disease?
• If you are concerned this is a new diagnosis of Crohn’s disease in a pregnant patient, do you:
- Perform a colonoscopy for tissue diagnosis?
- Treat empirically for Crohn’s disease? Which medication?
Colonoscopy with Biopsy
PATHOLOGY: ILEAL MUCOSA WITH MODERATE CHRONIC ACTIVE ILEITIS, ULCERATION AND FEATURES MOST CONSISTENT WITH MARKED REACTIVE LYMPHOID HYPERPLASIA; NEGATIVE CD3/CD20 STAINING (NO LYMPHOMA); NORMAL COLON BIOPSIES
Case Presentation
• Started on IV solumedrol with response and transitioned to budesonide
• Recrudescence of RLQ abd pain; budesonide → prednisone
• Seen in GI clinic to discuss initiation of biologic therapy
• Re-admitted a few days later with fever 102 F, abdominal pain, WBC 15K, thrombocytosis
Abdominal MRI
• Percutaneous drainage → 3 liters purulent fluid with cx + for MSSA and anaerobes
• One blood cx + MSSA; endocarditis evaluation negative
AbscessAir-fluid level in abscess
Abscess
Next Steps?
• Management of Crohn’s disease complicated by intra-abdominal abscess in pregnancy:
- Antibiotic considerations
- Drainage/surgery in gravid abdomen
• Biologic therapy in the setting of intra-abdominal abscess/pelvic sepsis:
- Timing of initiation
- Management of biologics in the 3rd trimester
Management of Intra-abdominal Abscess in Crohn’s Disease
Carvalho A et al. J Coloproctology 2018; 38(2):158-163
Non-Obstetric Abdominal Surgery in Pregnancy
• 2% of women require surgery for non-obstetric indications during pregnancy (appendectomy, cholecystectomy)
• lBD
- CD: perforation, obstruction, bleeding, perianal abscess
- UC: medically refractory disease
• Laparoscopic and open approaches are both feasible and need to be individualized to the clinical scenario
• Perioperative considerations
- Positioning in left lateral decubitus 2nd/3rd trimesters
- Pre and post-op fetal heart monitoring at viability
- Tocolytic agents if risk of pre-term labor
- VTE prophylaxisKilleen S et al. Colorectal Dis 2016; 19:123-138SAGES May 2017
Management of Biologics and Small Molecules in Pregnancy
Mahadevan U et al. Gastroenterology 156(5): 1508-1524
Case Presentation
• Treated with 4 weeks of ertapenum; drains removed
• Adalimumab initiated at conclusion of ertapenum course
• Healthy 37 week infant delivered 6 weeks after initiation of adalimumab
• 2 months post delivery the patient developed recurrent intra-abdominal fluid collections and underwent drainage followed by ileocecal resection
• Remains in clinical and endoscopic remission 4 years later on adalimumab 40 mg Q 2 weeks (6-MP added and withdrawn after one year of treatment)