Difficult IBD Cases

Shamita B. Shah, MD

Medical Director, Inflammatory Bowel Disease

Ochsner Medical Center, New Orleans

Disclosures

• Speaker for:

– Abbvie

– Janssen

– Pfizer

– Takeda

Case #1Sanya Wadhwa MD, PGY-VI

Gastroenterology Fellow

Ochsner Medical Center

• 36 yo M with hx of ulcerative colitis s/p restorative proctocolectomy and

IPAA in 2001 for disease refractory to medical treatment

• Dec 2016

– 6-8 loose BMs/day with occasional blood on TP and

– Some fecal seepage at night

Pouchoscopy showed mild to moderate pouch inflammation but

normal neoterminal ileum, with no treatment started at that time

• CT AP (Dec 2018)– Mild to moderate wall thickening involving the TI

– Interval development of presacral 6.6cm abscess with no obvious fistula/sinus tract

• Sent to ED for IV abx and discharged with PO abx

• IR abscess drainage outpatient (Jan 4, 2019)– 15 mL pus aspirated but not fully drained

• Pouchoscopy 1/11/2019– Normal neoterminal ileum (path – normal)

– Diffuse moderate pouchitis (path – mild active chronic enteritis)

– Very mild involvement of inflammation at the pouch inlet extending 2-3 cm proximal to the

inlet (path – mild active chronic enteritis)

• Abx for pouchitis: ciprofloxaCin/Flagyl

• EUA with transanal drainage of a horseshoe type presacral

supralevator abscess with drainage catheter placed

• Augmentin effective, drain removed

Pouchoscopy 3/2019 (moderate pouchitis, normal neo-TI,

bx no infection)

• What would you do next?

• Cipro/Flagyl ineffective

• Tindamax ineffective

• Augmentin effective though not complete resolution

• Repeat pouchoscopy due to ongoing symptoms

Pouchoscopy 4/11/2019

Severe pouchitis, mild distal neo-TI inflammation (5 cm

above pouch inlet), one cratered ulcer proximal to this

• Differential diagnosis?

• Next steps?

• Crohn’s disease of J pouch of concern with ongoing symptoms and

inflammation though improved ongoing

• IBD clinic: start Adalimumab with oral MTX weekly for treatment

• MRI Pelvis

• Severe pouchitis

• Large extraluminal presacral abscess

• Bilateral sacroillitis

• Treatment placed on hold

• IR drainage of abscess and 8 Fr drainage catheter placed

• Flagyl started

• 5/10/19: EUA by CRS - widened the sinus tract to facilitate

communication of the abscess cavity with the pouch itself and

placement of transanal 14 Fr drainage catheter into the abscess

cavity

• 5/24/19: CT AP - presacral abscess measuring 2.4 x 2.8 x 8.7 cm

• 5/25/19: EUA by CRS - large abscess cavity of about 8 cm was

found and stapled so it could communicate with distal pouch and

drain better, placement of drainage catheter

• 6/2019: improvement of symptoms with plans to continue flagyl and

repeat pouchoscopy

Pouchoscopy 8/13/2019- improved but ongoing pouchitis and

ongoing sx—diarrhea with anal leakage. Mild inflammation of

J pouch body, neoterminal ileum, rectal cuff- posterior sinus

tract from prior pre-sacral abscess with incision healing

• What would you do next?

• Humira, MTX started

• DDx: IBD unspecified vs reactive pouchitis from large

pre-sacral abscess

Case #2

Yilien Alonso MD, PGY-VI

Gastroenterology Fellow

Ochsner Medical Center

• 19-year-old male with a history of pan-colonic Crohn’s disease with perianal

abscess/fistula, diagnosed in 2016, previously on Humira and MTX though

noncompliant with his treatment

• Patient admitted in 5/17/19-5/24/19 for perianal pain

– CRS-performed EUA which showed multiple superficial perianal fistula and 2

perirectal abscess

◉ He underwent incision and drainage of abscess x 2 with placement of

Penrose drain, and subcutaneous fistulotomy x 2

Flex sigmoidoscopy 5/23/2019: mild inflammation in the rectum, severe

inflammation in the sigmoid colon, sigmoid colon stricture with edema and

inflammation, not traversed

Rectum Sigmoid

• Patient admitted in 6/17/19-6/19/19 with fever

– CRS removed Seton and placed patient on a course of antibiotics

• Patient admitted in 7/25/19-8/2/19 from infusion center due to fever

– Had received 2 doses of infliximab (Dose # 1 on 6/4 and Dose # 2 on 6/24)

– Fever workup initially unrevealing, started on antibiotics

– CT A/P: inflammatory changes in involving the small bowel, sigmoid, and

rectum as well as a new fluid and soft tissues collection between the rectum

and bladder concerning for evolving phlegmon/abscess

Colonoscopy 7/27/2019: Colonoscopy showed a normal rectum with a stricture at 20

cm from the anus which could not be traverse

Rectum Sigmoid

What’s the next best step in

management?

Drain collection and complete course of antibiotics?

Continue Remicade?

Surgery- if so, what type?

• Patient underwent surgery 2 days after the colonoscopy

– Exploratory laparotomy with sigmoid colectomy, small bowel resection, and

end colostomy

• Infliximab and MTX resumed ~ 2 weeks after surgery

– Infusion # 3: 8/16/19

– Infusion # 4: 9/16/19

– Infusion # 5: 11/11/19

– Infusion #3 and #4 administered at shorter intervals due to initial

delays in getting infusion # 3

Thank you!