Clinical Case Challenges in IBD: 5 Take-Home Messages

In this engaging session, 5 patients with complex and difficult cases of ulcerative colitis were presented to an expert panel, which consisted of Maria Abreu, MD, Edward Loftus, MD, and David Rubin, MD. The panel moderator was Jean-Paul Achkar, MD.

The cases were challenging even for gastroenterologists who specialize in the treatment of inflammatory bowel disease at tertiary referral centers. The case-based nature of the sessions kept participants more actively engaged than the more typical CME lecture format. Key take-home messages included:

1. Ulcerative colitis may have treatment options in common with other inflammatory conditions found in the same patient: In the case of a 36-year-old woman with multiple sclerosis who developed refractory ulcerative colitis, the panel suggested the use of natalizumab (Tysabri), an anti-TNF agent approved for the treatment of both multiple sclerosis and ulcerative colitis. As these agents proliferate, there will likely be other opportunities to treat two apparently disparate inflammatory diseases with a single potent anti-inflammatory.

2. If you are managing a patient with ulcerative colitis who does not respond to high-dose systemic corticosteroids, raise a red flag: The panel agreed that that either:
a. The patient has fulminant ulcerative colitis and is not likely to respond to medical therapy alone, or-
b. Your original diagnosis was incorrect-the patient does not actually have ulcerative colitis.  Other diagnoses must be excluded.

Once other diagnoses are excluded and the team has confirmed fulminant ulcerative colitis, timely surgical treatment is the best option. Most patients will resist early recommendations that may result in colostomy; trusted primary care advice will play an important role in mentally preparing patients for this possibility.

3. If your patient is treated presumptively for colitis with prolonged corticosteroid therapy, the finding of cytomegalovirus (CMV) on colonoscopic biopsy does not prove that infection is the primary process: Prednisone-induced immunosuppression can explain the finding of a positive CMV stain on colonoscopic biopsy. The patient in take-home message No. 2 (refractory to high-dose corticosteroids) initially presented to the local gastroenterologist with bloody diarrhea and weight loss but only had diffuse erythema and crypt abscesses on initial colonoscopic biopsy.  Presumptive treatment with corticosteroids and mesalamine was ineffective, but biopsy at a tertiary referral center initially was remarkable primarily for positive CMV stains. Repeated biopsy confirmed ulcerative colitis after CMV infection was cleared with gancyclovir.

4. Believe it or not, corticosteroid inhalers may have a role in treating an ulcerative colitis complication: No, they’re not inhaled. One panelist uses the inhalers as a spray to apply directly to stomal surfaces affected by periosteal pyoderma gangrenosum. Corticosteroid creams and ointments interfere with adherence of ostomy supplies; asthma and COPD inhalers represent an alternative non-greasy way to apply topical corticosteroids.

5. Transient histology suggestive of lymphoma: In a patient with Crohn disease who was aggressively treated with immunomodulators (6-MP, azathioprine, and infliximab), colonoscopic biopsy was read as “possible” lymphoma. Subsequent biopsy after immunomodulators were stopped showed resolution of histologic changes that had concerned the pathologist. This was a nice demonstration of the role of immune surveillance in cancer prevention.