By: Baldeep Pabla, MD MSCI
Case Presentation
A 23 year old male with a history of ileal and pan-colonic Crohn's disease s/p ileocolic resection with primary anastomosis in 2016 currently being treated with ustekinumab and methotrexate presents to the clinic for progressively worsening abdominal pain in the fall of 2022.
Intestinal Ultrasound Assessment
Intestinal ultrasound is performed early in the outpatient visit and demonstrates circumferential bowel wall thickening with markedly increased thickness of the mucosa (black) and submucosa (gray) bowel wall layers. There is also clearly visualized luminal narrowing with proximal dilation of the neo-terminal ileum.
Color Doppler signal of the anastomotic stricture is assessed to help determine the degree of active inflammation vs. fibrosis to guide next steps in management.
After his clinic visit, he does not follow up with recommendations for repeat assessment with ileocolonoscopy and is lost to follow up for one year. He then returns one year later with progressive obstructive symptoms and mild weight loss with several recent courses of budesonide. He undergoes an intestinal ultrasound examination again at the point-of-care.
Reassessment with Intestinal Ultrasound
Color Doppler signal again is assessed with intestinal ultrasound to help determine the component of active inflammation at the anastomotic stricture.
Ileocolonoscocopy
Ileocolonoscopy is performed one month after his most recent intestinal ultrasound in the setting of persistent and worsening abdominal pain.
After the stricture was identified at the ileo-colic anastomosis, a balloon dilation was performed to 12 mm antegrade and then to 15 mm retrograde. There were mild vascular changes.
The neo-terminal ileum was visualized post-dilation and was notable for very mild active inflammation with a few scattered aphthae.
Conclusion
After his ileocolonoscopy with balloon dilation, the patient switched treatment from ustekinumab and methotrexate to upadacitinib. He achieved clinical remission 3 months later.
