Case 7: 45-year-old male with recent surgical resection for Crohn’s disease
VISIT 1 Day 2 after Crohn’s disease resection
Patient is in discomfort but the pain medication is helping. He is tolerating clear fluids and the plan is to advance his diet tomorrow.
Prior to surgery patient was taking azathioprine for 3 years and smoked half a pack of cigarettes per day
The doctor states that early intervention after surgery is important to reduce the risk of the inflammation returning.
– Once the patient starts to eat, metronidazole (Flagyl) will be started start for 1 year, as there is evidence to support using this antibiotic in this way can reduce chance of Crohn’s coming back after surgery.
– Azathioprine was restarted once discharged from hospital.
– Smoking cessation was encouraged to reduce the risk of recurrent Crohn’s disease.
VISIT 2 6 months after surgery: colonoscopy
Though the patient is feeling well, he was told that inflammation can be seen at the site of previous surgery. If such inflammation is present, it suggests that the current medical therapy is failing and therefore the patient would be willing to improve his therapy.
The colonoscopy shows many small ulcers at the site of the previous surgery.
The doctor orders a special test, called 6-TGN blood test, to determine if azathioprine is properly dosed.
VISIT 3 2 weeks later
The patient continues to take metronidazole and azathioprine.
The doctor calls the patient to tell him the 6-TGN level was low.
– Increase the dose of azathioprine
– Repeat the colonoscopy 4 months later
4 months later the colonoscopy shows healing of the bowel (the previous ulcers have disappeared).
Patients who require surgery for Crohn’s disease represent a particularly high risk group of patients which may end up with significant long-term problems. Because of this fact, ensuring inflammation related to Crohn’s disease is well controlled is a critical issue. Therefore looking for evidence of Crohn’s disease with a colonoscopy is a commonly used strategy after surgery.