Curbside Consultation in IBD 49 Clinical Questions

by Rubin, David T.; Friedman, Sonia; Farraye, Francis A.

• ISBN13: 9781556428562
• ISBN10: 1556428561
• Format: Paperback
• Copyright: 2009-04-15
• Publisher: Slack Incorporated

Summary

Are you looking for concise, practical answers to questions that are often left unanswered by traditional IBD references? Are you seeking brief, evidence-based advice for complicated cases or complications?Curbside Consultation in IBD: 49 Clinical Questionsprovides quick and direct answers to the thorny questions commonly posed during a "curbside consultation" between colleagues. Dr. David Rubin, Dr. Sonia Friedman and Dr. Francis A. Farraye have designed this unique reference, which offers expert advice, preferences, and opinions on tough clinical questions commonly associated with IBD. The unique Q&A format provides quick access to current information related to IBD with the simplicity of a conversation between two colleagues. Numerous images, diagrams, and references are included to enhance the text and to illustrate IBD. Curbside Consultation in IBD: 49 Clinical Questionsprovides information that high-volume clinicians will appreciate, and yet is basic enough for residents. Gastroenterologists, fellows and residents in training, surgical attendings, and surgical residents will benefit from the user-friendly and casual format and the expert advice contained within. Some of the questions that are answered: bull; Which patients might be better for a "top down" approach (using anti-TNF therapy before steroids or proven failure of oral thiopurines)? What clinical behavior or serological markers might you use to identify these patients? bull; When is it appropriate to switch to another biologic therapy? bull; Should I be using chromoendoscopy in my surveillance colonoscopy in IBD? How and which agent? Would narrow band imaging be an alternative for this? bull; Can we follow flat low-grade dysplasia? Is any dysplasia really flat or just a spectrum of depth and size? bull; If women continue infliximab therapy during pregnancy, what are the implications for the baby? What should we be telling our patients about vaccinations?

Author Biography

David T. Rubin, MD, FACG, AGAF is an Associate Professor of Medicine, the Program Director for the Fellowship in Gastroenterology, Hepatology, and Nutrition, and the Co-Director of the Inflammatory Bowel Disease Center at the University of Chicago Medical Center in Chicago, IL. He is an Associate Faculty Member of the University of Chicago MacLean Center for Clinical Medical Ethics, and an investigator in the Cancer Research Center of the University of Chicago. Dr. Rubin earned his doctor of medicine degree with honors from the University of Chicago Pritzker School of Medicine. He completed his residency in internal medicine and both of his fellowships in gastroenterology and clinical medical ethics at the University of Chicago, where he served as Chief Resident and Chief Fellow. Dr. Rubin is a member of the American Gastroenterology Association (AGA), previously serving on the Ethics Committee and currently serving on the Subcommittee for Training and the Public Affairs and Advocacy Committee. He is a Fellow of the American College of Gastroenterology (ACG), serving on the Professional Issues and Publications Committee. He is also a member of the Crohn’s and Colitis Foundation of America (CCFA) and has chaired the CCFA Illinois Educational Program from 2005 to 2008. He also served as Chair of Professional Education for CCFA nationally, and directed the national fellowship and preceptorship programs from 2005-2008. An avid researcher, Dr. Rubin’s interests include clinical outcomes of inflammatory bowel disease (IBD), colon cancer screening and prevention, teaching medicine, and clinical medical ethics. He is currently the principal investigator for several research projects and clinical trials involving wireless capsule endoscopy in IBD, measures of inflammation and cancer risk, and novel technologies for disease monitoring. Dr. Rubin has contributed numerous peer-reviewed publications, book chapters, review articles, and abstracts to the medical literature, including a previous handbook for the hospitalized IBD patient. Sonia Friedman, MD is an Assistant Professor of Medicine at Harvard Medical School in Boston, MA, and an Associate Physician at Brigham and Women’s Hospital, also in Boston. Dr. Friedman completed her undergraduate degree in biology at Stanford University in Palo Alto, CA, and her medical degree at Yale University School of Medicine in New Haven, CT. She did her medical internship and residency at the University of Pennsylvania in Philadelphia, PA, and her gastroenterology fellowship at Mount Sinai Medical Center in New York, NY. She specialized in IBD during her fellowship and now has a large IBD practice in the gastroenterology division of Brigham and Women’s Hospital. She has been at Brigham and Women’s for the past 9 years, and is Director of IBD Clinical Research. Dr. Friedman’s research interests include colon cancer in Crohn’s disease (CD), patient adherence to surveillance colonoscopy and to IBD medications, and IBD and pregnancy. Her clinical interests are the care of patients with CD and ulcerative colitis (UC). She specializes in the management of dysplasia and cancer in IBD, and pregnancy and IBD. Dr. Friedman is a frequent speaker and invited regional and national lecturer on the management of IBD. She has authored or coauthored peer-reviewed papers on cancer in CD, management of polyps and cancer in IBD, medical management of IBD, and pregnancy and IBD. She has written review articles and chapters on various aspects of IBD, including the IBD chapter in Harrison’s Principles of Internal Medicine. Her publications include original articles, reviews, or chapters in Gastroenterology, Clinical Gastroenterology and Hepatology, American Journal of Gastroenterology, Inflammatory Bowel Diseases, and Gastroenterology Clinics of North America. She is section editor for Inflammatory Bowel Diseases, and is a reviewer for Gastroenterology, Clinical Gastroenterology and Hepatology, and American Journal of Gastroenterology. Dr. Friedman is chair-elect of the CCFA New England Chapter Medical Advisory Committee, and is co-chair of their annual patient symposium. She is a Fellow of the ACG and has served on the CCFA Professional Education Committee. She has been elected as “Best Up-and-Coming Gastroenterologist in Boston” in 2004, and was also listed as “Best of Boston” in Boston Magazine in 2007. Both honors are based upon peer review. Francis A. Farraye, MD, MSc, FACG, FASGE is a Professor of Medicine at the Boston University School of Medicine in Boston, MA. He is also Clinical Director in the Section of Gastroenterology and Co-Director of the Center for Digestive Disorders at Boston Medical Center. After graduating from the State University of New York (SUNY) at Stony Brook, Dr. Farraye earned his medical doctorate from Albert Einstein College of Medicine in New York, NY, and his master’s degree in Epidemiology from the Harvard School of Public Health in Boston, MA. He completed an internal medicine residency and gastroenterology fellowship at the Beth Israel Hospital in Boston. Dr. Farraye’s clinical interests are in the care of patients with IBD, the management of colon polyps and colorectal cancer, as well endoscopy in patients after bariatric surgery. He is studying Vitamin D absorption in patients with IBD, the management and diagnosis of dysplasia and cancer in patients with IBD, and predictors of pouchitis after ileal pouch-anal anastomosis (IPAA). In the area of colorectal cancer, he is examining the role of hyperplastic polyps as an alternative pathway in the development of colorectal cancer. A frequent speaker and invited lecturer on topics on the diagnosis and management of IBD, Dr. Farraye has authored or coauthored over 150 original scientific manuscripts, chapters, reviews, and abstracts. His work has been published in the American Journal of Gastroenterology, Gastroenterology, Alimentary Pharmacology and Therapeutics, Gastrointestinal Endoscopy, Annals of Internal Medicine, and JAMA, among others. He is a coeditor for the text Bariatric Surgery: A Primer for your Medical Practice, and an associate editor for Therapy for Digestive Disorders. He recently edited an issue of Gastroenterology Clinics of North America on dysplasia and cancer in IBD. He is the series editor for the Curbside Consultations in Gastroenterology series. Dr. Farraye is a Fellow of the American College of Physicians, American Society of Gastrointestinal Endoscopy, and the ACG. Nationally, he serves as Chair of the Board of Governors and a member of the Board of Trustees in the ACG. He has served as the AGA representative on the National Colorectal Cancer Round Table as Co-Chair of the Standards Committee and as Chair of the Lower Gastrointestinal Disorders Section of the Annual Scientific Program Committee of the ASGE. He is a member of the ASGE Technology Committee, CCFA Professional Education Committee, and the Chapter Medical Advisory Committee for the New England CCFA, where he is a past chairman. The New England CCFA named Dr. Farraye “Humanitarian of the Year” in 2003.

Table of Contents

Dedication	p. v
Acknowledgments	p. xiii
About the Editors	p. xv
Contributing Authors	p. xix
Preface	p. xxiii
Foreword	p. xxv
I Recently Did a Colonoscopy on a Patient With Rectal Bleeding. The Patient Had Inflammation in the Rectosigmoid and Also in the Cecal Area. Is This Crohn's Disease?	p. 1
When Is it Appropriate to Switch to Another Biologic Therapy?	p. 5
Is There Ever a Time to Switch 5-Aminosalicyclic Acids in Ulcerative Colitis?	p. 11
When and How Do You Use Aminosalicylates in Crohn's Disease? How Do You Monitor Response to Therapy With These Agents?	p. 13
What Is the Role of Concomitant Immunomodulators With Biologic Use in Inflammatory Bowel Disease?	p. 15
What New Drugs Have Recently Been Released to Treat Inflammatory Bowel Disease? What New Drugs Can We Anticipate Being Released in the Next 5 Years? How Will They Change Our Treatment Algorithms?	p. 21
What Are the Risks of Biologic Therapies, and How Do You Communicate This to Patients?	p. 27
Should I Measure Thiopurine Methyltransferase Genotype or Enzyme Activity Before Starting a Patient on Azathioprine or 6-Mercaptopurine?	p. 33
How do You Monitor Patients on Azathioprine/6-Mercaptopurine?	p. 39
How Long Do You Wait Before Declaring Treatment Failure With Azathiprine/6-Mercaptopurine, and Do You Ever Consider Stopping Therapy With These Agents After a Period of Time?	p. 45
My Partner Uses Methotrexate as His First Line Agent in Crohn's Disease. How Do You Choose Between 6-Mercaptopurine and Methotrexate?	p. 47
If I Want to Use Methotrexate for My Patients With Crohn's Disease, What Dose(s) and What Route of Administration (Subcutaneous, Intramuscular, or Oral) Should I Use? Is There a Risk of Hepatotoxicity or Pulmonary Toxicity?	p. 49
Which Patients Might Be Better for a "Top-Down" Approach (Using Anti-Tumor Necrosis Factor Therapy Before Steroids or Proven Failure of Oral Thiopurines)? What Clinical Behavior or Serological Markers Might You Use to Identify These Patients?	p. 51
How Do You Approach Polypoid Lesions in Patient With Inflammatory Bowel Disease?	p. 57
Should I Be Using Chromoendoscopy in My Surveillance Colonoscopy in Inflammatory Bowel Disease? How and Which Agent? Would Narrow Band Imaging Be an Alternative for This?	p. 63
Can We Follow Flat Low-Grade Dysplasia? Is Any Dysplasia Really Flat or Just a Spectrum of Depth and Size?	p. 67
Can Medications Like Folic Acid, Ursodeoxycholic Acid, or 5-Aminosalicyclic Acids Lower the Risk of Colorectal Cancer or Dysplasia in Patients With Inflammatory Bowel Disease?	p. 71
Which of My Inflammatory Bowel Disease Patients Should I Screen for Osteoporosis? Should I Also Screen for Vitamin D Deficiency?	p. 75
How Do You Screen and Survey for Dysplasia in Crohn's Patients? Can You Perform Segmental Resection in Crohn's Patients With Dysplasia?	p. 79
What Should We Be Telling Our Patients and Their Pediatricians About Using Anti-Tumor Necrosis Factor Alpha Therapy During Pregnancy?	p. 83
What Are the Risks to the Fetus and to the Baby Regarding Azathioprine and 6-Mercaptopurine in Pregnancy and Nursing?	p. 87
My 25-Year-Old Patient With Crohn's Disease on Azathioprine Was Recently Diagnosed With HPV. Is it Safe to Continue the Azathioprine?	p. 91
What Is the Role of Computed Tomographic Enterography in the Diagnosis and Management of Inflammatory Bowel Disease? Has it Replaced Barium Radiography?	p. 93
I Recently Did a Capsule Endoscopy on a Young Patient With Diarrhea. The Colonoscopy, Endoscopy, and Biopsies Were All Normal, but the Capsule Showed Several Erosions Scattered Throughout the Small Bowel. Is This Crohn's Disease?	p. 97
How Do You Diagnose Pouchitis?	p. 101
How Do You Treat Pouchitis?	p. 105
My Partner Tells Me That "Serology 7" Profiles Can Predict Which Crohn's Disease Patients Will Progress Rapidly. Should I Order This for All of My Newly Diagnosed Crohn's Disease Patients? Are There Additional Clinical or Genetic Factors That Identify a High-Risk Group?	p. 109
Do Any Medications Slow the Progression of Primary Sclerosing Cholangitis?	p. 113
What Is the Best Approach to Dosing Cyclosporine for Severe Ulcerative Colitis? Can Infliximab Be Used Before Cyclosporine Dosing? Can Cyclosporine Be Used Before Infliximab?	p. 117
When Should Bowel Rest or Elemental Feeding Be Used in the Management of Crohn's Disease?	p. 121
How Do You Treat Microscopic Colitis?	p. 127
Should I Dilate Colonic Strictures in Patients With Crohn's Disease?	p. 131
Is There a Role for Measuring C-Reactive Protein, Erythrocyte Sedimentation Rate, or Fecal Calprotectin in My Inflammatory Bowel Disease Patients?	p. 135
What Is the Definition of Corticosteroid Dependence? How Do I Treat Patients With Corticosteroid-Dependent Inflammatory Bowel Disease?	p. 139
How Can I Clarify the Diagnosis in My Patient With Indeterminate Colitis?	p. 143
How Should I Treat My Crohn's Patient Postoperatively?	p. 147
Is it Safe and Effective to Vaccinate My Patient With Inflammatory Bowel Disease?	p. 151
What Is the Risk of Developing Lymphoma in My Patients With Crohn's Disease, and Do the Immunomodulators and Biologic Agents Increase the Risk?	p. 157
How Do You Dose 5-Aminosalicyclic Acids? When Do You Use Topical Therapy? How Do You Monitor During Therapy?	p. 161
Do Probiotics Have a Role in Treating Inflammatory Bowel Disease Patients?	p. 165
What Is Your First Line Approach to the Diagnosis and Treatment of Patients With Perianal Crohn's Disease?	p. 169
How Do You Handle an Inflammatory Bowel Disease Patient With Clostridium Difficile Infection?	p. 173
How Do You Manage Moderate to Severe Duodenal Crohn's Disease?	p. 177
What Is the Necessary Testing That Should Be Performed Before Initiating Biologic Therapy?	p. 181
How Do You Manage Pyoderma Gangrenosum in the Setting of Inflammatory Bowel Disease?	p. 185
My 25-Year-Old Patient Has Diffuse Arthralgias. Can He Take Non-Steroidal Anti-Inflammatory Drugs?	p. 189
My Patient Has a History of Breast Cancer and Is in Remission From That Condition. She Also Has Crohn's Disease. Can I Use Azathioprine or Infliximab to Treat Her?	p. 193
I Have a Patient Whose Brother Has Crohn's Disease. Is There Anything I Should Tell Him to Prevent Disease Onset or to Diagnose the Disease Sooner?	p. 197
Is the Diagnosis, Treatment, and Response to Treatment Different in Nonwhites?	p. 201
Index	p. 205
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