Challenging IBD Cases

Nancy McGreal, MDAssociate Professor of Medicine and Pediatrics

Divisions of Adult and Pediatric GastroenterologyDuke University Medical Center

Disclosures

• None

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

Mahadevan U et al. Gastroenterology 156(5): 1508-1524

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)

Thank You for Your Time and Attention