A young female w/ history of Crohn’s in remission presents with fever + RUQ pain found to have transaminitis + neutropenia with an odd-looking “collapsed gallbladder” on imaging. She is being treated broadly for cholecystitis, but the underlying cause of her imaging findings is still unclear; GI and Surgery are involved.
1. Although PSC more commonly occurs in UC patients, it is also (though less) associated with Crohn’s Disease.
2. Acute Liver FAILURE requires the presence of INR > 1.5 and encephalopathy. This patient did NOT have acute liver failure.
3. Neutropenic fever pearls
-As Morgan noted, the diagnosis and management of “neutropenic fever” we often discuss strictly applies to chemotherapy-induced neutropenia. The infectious risk in patients with non-chemotherapy neutropenia of unclear etiology ranges from benign to life-threatening; the infectious risk is highest when neutropenia is related to bone marrow suppression or vasculitis. However, when the risk is unknown it is reasonable to manage ALL people with neutropenic fever with broad-spectrum antibiotics including pseudomonal coverage.
-Infectious risks are highest when ANC < 500 AND duration of neutropenia is >7 days
A young man w/ Crohn’s disease presents with complex peri-rectal disease c/b inadequate response to anti-TNF therapy and c. diff, ultimately requiring surgical intervention.
Standard of care for characterizing complex peri-rectal disease:
-Pelvic MRI – particularly in young patients to avoid radiation exposure!!
Bad prognosticators for Crohn’s:
-Deep ulcerations at time of endoscopy
-CRP > 5
What to do if a patient is not responding to infliximab:
-Check a trough level
-Also check antibody – human anti-chimeric antibody (HACA)
-Can consider dual therapy with an immunomodulator like Remicade – must counsel patients on long term risk of lymphoma
C. Diff and IBD
-C. Diff is very common in these patients, and you must ALWAYS rule out C. Diff!