Q1: ANSWER: D
Critique
The patient has had complicated recurrent Crohn’s disease and two resections. If this were his first resection of a short-segment ileal stricture, then choice (a) would be a reasonable alternative to starting medication at this time. This is based on the endoscopic scoring system of Rutgeerts in which endoscopic findings in the neoterminal ileum at 6-12 months postoperatively are somewhat predictive of clinical recurrence over the next 5 years. Short-term antibiotic therapy with ciprofloxacin has not been shown to be a good long-term solution to prevention of postoperative recurrence. Both azathioprine and 6-mercaptopurine have a modest effect on the prevention of postoperative recurrence of Crohn’s disease. Azathioprine at 1 mg/kg per day would be less than an optimal dose for this purpose. The D’Haens study used 1.5-2 mg/kg of azathioprine in combination with 3 months of metronidazole. At 1 year the endoscopic recurrence rate (i2-i4 lesions) was greater in the placebo group at 69% compared with 44% in the azathioprine-treated group. Infliximab has been shown in a small randomized trial to be very effective in preventing postoperative recurrence of Crohn’s disease. In a 24-subject randomized trial, 91% of the infliximab treated patients were free of endoscopic recurrence, compared to 9% of patients receiving placebo. In this patient, who is at a high risk for recurrence with recurrent inflammation, multiple surgeries, and continued smoking, anti-TNF therapy should be initiated within 4 weeks after surgery. Mesalamine has minimal postoperative preventative effects and would not be appropriate monotherapy to use in this high-risk patient.
References
1. D’Haens, G.R., Vermeire, S., Van Assche G., et al. Therapy of metronidazole with azathioprine to prevent postoperative recurrence of Crohn’s disease: a controlled randomized trial. Gastroenterology 2008;135:1123-9.
2. Regueiro, M., Schraut, W., Baidoo, L., et al. Infliximab prevents Crohn’s disease recurrence after ileal resection. Gastroenterology 2009;136:441-50.e1;quiz 716. Epub 2008 Oct 31.
3. Rutgeerts P, Geboes K, Vantrappen G, Beyls J, Kerremans R, Hiele M. Predictability of the postoperative course of Crohn’s disease. Gastroenterology 1990;99:956-63.
4. Schwartz M, Regueiro M. Prevention and treatment of postoperative Crohn’s disease recurrence: an update for a new decade. Curr. Gastroenterol. Rep. 2011;13:95-100.
