1. IBD Patient Update Case Vignettes 12 November 2011

2. Case #1 J.O. is a 22 yo graduate student diagnosed with Ulcerative proctosigmoiditis 2 years ago and has been treated 5-ASA three tabs 3x daily (3.6g). Since beginning grad school, he has had increased fecal urgency, and rectal bleeding. Non smoker no NSAIDs “usually takes at least 1 tab of 5-ASA a day”

3. Case #1 questions Is this my U.C.? How can I tell? Do I really need to take my medicines as prescribed? Do I need to step-up my regimen? Is there an alternative to my regimen? Can stress affect my symptoms?

4. Case #2 W.B. is a 41 yo male with a 15 year history of ileo-colonic Crohn’s disease Treated with Azathioprine for past 5 yrs Over the past year, he has had two hospitalizations for partial small bowel obstruction CT Enterography identified 2 cm stricture in the distal ileum.

5. Case #2 Questions What are the surgical options for the management of small bowel Crohn’s strictures? Are there any medical options for the management of these strictures?

6. Case #3 S.E. is a 28 yo female with Crohn’s ileocolitis who has had worsening symptoms over the past few months while on Pentasa. Last week she was started on Azathioprine. Developed severe nausea, vomiting and abdominal discomfort and discontinued the medication.

7. Case #3 Questions What are some of the risks and side effects of Azathioprine? Is there any way to mitigate potential risks before starting Azathioprine? If I develop side effects from Azathioprine are there other options available to me? If prescribed a new medication, how long will I need to be on it?

8. Case #4 JR is a 45 yo male with 2 year history of ulcerative pancolitis Asacol 3.6g and AZA of 100mg daily Over past few months –increasing fecal urgency –recurrence of rectal bleeding Stool negative for C. Difficile Anemia and increased ESR and CRP Flex sig showed: severe inflammation

9. Case #4 Questions F.S. started on prednisone 40mg daily How long will I be on Prednisone? Do I need to change my medical regimen? Will I need a colectomy?

10. Case #5 S.S. is a 28 yo female with a 2 year history of left- sided UC diagnosed by colonoscopy Canasa suppositories and Asacol 2.4g/day –Her symptoms resolved. Discontinued Asacol after a few months Discontinued Canasa suppositories 6 mos ago Over the past 3 mos - Diarrhea and bloody stool Presented to ED - felt to be a UC flare. Routine urine pregnancy test is positive.

11. Case #5 Questions Doesn’t my disease affect my chances of having become pregnant? Does my disease affect my pregnancy? Will my pregnancy affect my disease? Are my medications safe during pregnancy? If my symptoms don’t continue to improve do I have other medical options?

12. Case #6 D.F. is a 45 yo male with Crohn’s pan-colitis diagnosed 8 years ago who is asymptomatic on 5-ASA 2.4g daily. He underwent colonoscopy by his gastroenterologist to survey for dysplasia. Random biopsies were taken throughout his colon. No dysplasia was seen. He was told to have a repeat colonoscopy in 1-2 years.

13. Case #6 Questions Is there increased risk of colon cancer in Crohn’s disease? What is dyplasia? How often should I undergo colonoscopy to look for precancerous changes? Is there anything I can do to decrease my risk of dysplasia and colorectal cancer?

14. Case #7 F.S. is a 36 yo male contractor with Crohn’s ileocolitis which has been well managed on azathioprine 100mg daily. He recently started a new job 2 months ago. Every weekday morning while at work he has urgency, bloating and lower abdominal cramping which resolves by the evening. He was asymptomatic during a recent 7 day vacation. However, symptoms recurred upon his return.

15. Case #7 Questions Is this my Crohn’s disease? Are there tests to help decide if this is my IBD or IBS? Are there certain foods I should avoid that may be complicating my symptoms? Is it safe for me to take anti-diarrheals? What change in symptoms should be of concern?

16. Case #8 ZE is a 19 yo female recently diagnosed with Ulcerative Colitis during an evaluation for rectal bleeding and fecal urgency. She was initially treated with 5-ASA Elected to pursue a homeopathic approach –discontinued her 5-ASA therapy She has had recurrence of rectal bleeding and abdominal pain prompting a hospital admission

17. Case #8 Questions What are the real risks of my medical therapy? What are the risks of not taking my medical therapy? What nutritional options are available? What stress management options area available?