A 33-year-old woman with Crohn’s disease colitis presents to her physician after 2 days of photophobia and blurred vision. She has had no similar episodes in the past. She has no abdominal pain or diarrhea and takes mesalazine, azathioprine, and prednisone as maintenance therapy. Her vital signs are within normal range. Examination of the eyes shows conjunctival injection. The physical examination is otherwise normal. Slit-lamp examination by an ophthalmologist shows evidence of inflammation in the anterior chamber. Which of the following is the most appropriate modification to this patient’s medication at this time?

No modification of therapy at this time

Decreasing dose of azathioprine

A 62-year-old man comes to the physician in May for a routine health maintenance examination. He feels well. He underwent a right inguinal hernia repair 6 months ago. He has hypertension and type 2 diabetes mellitus. There is no family history of serious illness. Current medications include metformin, sitagliptin, enalapril, and metoprolol. He received the zoster vaccine 1 year ago. He received the PPSV23 vaccine 4 years ago. His last colonoscopy was 7 years ago and was normal. He smoked a pack of cigarettes a day for 20 years but quit 17 years ago. He drinks two to three alcoholic beverages on weekends. He is allergic to amoxicillin. He is scheduled to visit Australia and New Zealand in 2 weeks to celebrate his 25th wedding anniversary. He appears healthy. Vital signs are within normal limits. An S4 is heard at the apex. The remainder of the examination shows no abnormalities. Which of the following is the most appropriate recommendation at this time?

Pneumococcal conjugate vaccine 13

An 11-month-old boy is brought to a pediatrician by his parents for evaluation of vomiting and watery diarrhea over the last day. The mother informs the pediatrician that the boy had consumed an apple bought from a fruit vendor on the previous day, but that otherwise there has been no recent change in his diet. There is no history of blood in the stool, flatulence, irritability, or poor appetite. There is no history of recurrent or chronic diarrhea or any other gastrointestinal symptoms. On physical examination, his temperature is 37.6°C (99.6°F), pulse is 120/min, respirations are 24/min, and blood pressure is 92/60 mm Hg. General examination reveals a playful infant with normal skin turgor and no sunken eyes. The pediatrician explains to the parents that he most likely has acute gastroenteritis and that no specific medication is indicated at present. He also instructs the parents about his diet during the illness and reviews the danger signs of dehydration. He suggests a follow-up evaluation after 48 hours or earlier if any complications arise. Which of the following dietary recommendations did the pediatrician make?

Plenty of juices and carbonated sodas

Three days after admission to the hospital with a clinical diagnosis of ischemic colitis, a 65-year-old man has recovered from his initial symptoms of bloody diarrhea and abdominal pain with tenderness. He feels well at this point and wishes to go home. He has a 15-year history of diabetes mellitus. Currently, he receives nothing by mouth, and he is on IV fluids, antibiotics, and insulin. His temperature is 36.7°C (98.1°F), pulse is 68/min, respiratory rate is 13/min, and blood pressure is 115/70 mm Hg. Physical examination of the abdomen shows no abnormalities. His most recent laboratory studies are all within normal limits, including glucose. Which of the following is the most appropriate next step in management?

Discharge home with follow-up in one month

Five days after undergoing an open abdominal aortic aneurysm repair, a 68-year-old woman has crampy abdominal pain. During this period, she has also had two episodes of loose, bloody stools. Her surgery was complicated by severe blood loss requiring the administration of vasopressors and multiple transfusions. Cefazolin was administered as a perioperative antibiotic. The patient has hypertension, hypercholesterolemia, and coronary artery disease. The patient has smoked 2 packs of cigarettes daily for 50 years and drinks 3–4 glasses of wine every week. Her current medications include hydrochlorothiazide, atorvastatin, amlodipine, aspirin, and metoprolol. She appears ill. Her temperature is 38.0°C (100.4°F), pulse is 110/min, and blood pressure is 96/58 mm Hg. Physical examination shows a distended abdomen with absent bowel sounds. The abdomen is exquisitely tender to palpation in all quadrants. The lungs are clear to auscultation. Cardiac examination shows an S4 gallop. An x-ray of the abdomen shows air-filled distended bowel. Which of the following is the most likely diagnosis?

Abdominal aortic aneurysm rupture

Background and Methods: Aldosterone is important in the pathophysiology of heart failure. In a double-blind study, we enrolled 1,663 patients who had severe heart failure, a left ventricular ejection fraction of no more than 35 percent, and were being treated with an angiotensin-converting-enzyme inhibitor, a loop diuretic, and in most cases digoxin. A total of 822 patients were randomly assigned to receive 25 mg of spironolactone daily and 841 to receive placebo. The primary endpoint was death from all causes. Results: The trial was discontinued early, after a mean follow-up period of 24 months, because an interim analysis determined that spironolactone was efficacious. There were 386 deaths in the placebo group (46%) and 284 in the spironolactone group (35%; relative risk of death, 0.70; 95% confidence interval, 0.60 to 0.82; p<0.001). This 30 percent reduction in the risk of death among patients in the spironolactone group was attributed to a lower risk of both death from progressive heart failure and sudden death from cardiac causes. The frequency of hospitalization for worsening heart failure was 35% lower in the spironolactone group than in the placebo group (relative risk of hospitalization, 0.65; 95% confidence interval, 0.54 to 0.77; p<0.001). In addition, patients who received spironolactone had a significant improvement in the symptoms of heart failure, as assessed on the basis of the New York Heart Association functional class (p<0.001). Gynecomastia was reported in 10% of men who were treated with spironolactone, as compared with 1% of men in the placebo group (p<0.001). The incidence of serious hyperkalemia was minimal in both groups of patients. Which of the following statements represents the most accurate interpretation of the results from the aforementioned clinical trial?

Spironolactone, in addition to standard therapy, substantially reduces the risk of morbidity and death in patients with severe heart failure

The incidence of both gynecomastia and hyperkalemia was elevated in patients treated with spironolactone

Spironolactone did not improve all-cause morbidity and mortality in patients with severe heart failure

Given the large sample size of this clinical trial, the results are likely generalizable to all patients with heart failure

The addition of spironolactone significantly improved symptoms of heart failure, but not overall mortality

IBD in special populations for USMLE Step 1: High-Yield Internal Medicine Lessons

IBD in Pregnancy - Bumps & Bowels

Fertility: Unaffected in inactive IBD. May be ↓ in active disease, especially with pelvic surgery (e.g., IPAA).
Pregnancy Outcomes: Disease activity is the key predictor.
- Active IBD: ↑ risk of preterm birth (< 37 weeks), low birth weight (< 2500 g), and miscarriage.
- Inactive IBD: Outcomes are comparable to the general population.

⭐> The single most important factor for a healthy pregnancy is achieving and maintaining remission for at least 3-6 months prior to conception.

Medication Management in Pregnancy & Lactation

Medication Class	Pregnancy/Lactation Safety
5-ASA Agents	Generally safe; supplement with high-dose folate ($2$ mg/day).
Corticosteroids	Safe for flares; monitor for gestational diabetes/hypertension.
Thiopurines	Generally safe; benefits of maintaining remission outweigh risks.
Anti-TNFα	Generally safe; may consider holding in the third trimester.
Methotrexate	⚠️ Contraindicated (teratogen); stop 3-6 months before conception.

IBD in the Elderly - Golden Year Guts

Diagnostic Challenges: Symptoms mimic other geriatric conditions like ischemic colitis, diverticulitis, and malignancy. A high index of suspicion is crucial.
Disease Presentation:
- ↑ incidence of Ulcerative Colitis (UC), often left-sided (proctitis).
- Crohn's Disease (CD) is more commonly colonic (L2) and non-stricturing.
Management Considerations:
- Higher risk of opportunistic infections and malignancy with immunosuppressants.
- Polypharmacy & comorbidities complicate treatment.
- Cautious use of steroids due to ↑ risk of side effects (osteoporosis, hyperglycemia).

⭐ Exam Favorite: Elderly IBD patients have a significantly higher risk of severe Clostridioides difficile infection, which is associated with increased morbidity and mortality.

Pediatric IBD - Growing Pains

Pediatric growth chart showing growth failure in Crohn's

Unique Presentation: Growth failure is a highly specific sign. Look for delayed puberty, malnutrition, weight loss, and anemia. Abdominal pain can be less prominent than in adults.
Disease Patterns:
- Crohn's Disease (CD): Typically more extensive, often ileocolonic (L3) disease.
- Ulcerative Colitis (UC): More likely to present as pancolitis (~80% of cases), leading to a more severe initial course.

⭐ Primary Therapy: Exclusive Enteral Nutrition (EEN) is a first-line, steroid-sparing therapy to induce remission in pediatric CD, promoting mucosal healing and catch-up growth.

Post-Surgical IBD - After the Cut

Crohn's Disease (CD): High recurrence risk after resection.
- Risk Factors: Smoking, penetrating/fistulizing disease, prior resections.
- Surveillance: Ileocolonoscopy at 6-12 months post-op to guide therapy.
- Staging: Rutgeerts score (i2-i4) indicates need for treatment escalation (e.g., biologics).
Ulcerative Colitis (UC): Pouchitis after total proctocolectomy with IPAA.
- Acute Pouchitis Tx: Ciprofloxacin or Metronidazole.
- Chronic Pouchitis: Consider probiotics (e.g., VSL#3) or long-term antibiotics.

⭐ Up to 80% of Crohn's patients experience endoscopic recurrence within one year of surgery without prophylactic treatment.

High‑Yield Points - ⚡ Biggest Takeaways

Pregnancy & IBD: Most meds are safe, except methotrexate and thalidomide. Disease control before conception is crucial for better maternal and fetal outcomes.

Elderly Onset: Often presents atypically. Higher risk of C. difficile, malignancy, and medication side effects. Biologics require cautious use.

Pediatric IBD: Key features include growth failure and delayed puberty. Exclusive enteral nutrition is a first-line therapy, especially in Crohn's disease.

Post-Surgery: Proctocolectomy with IPAA is curative for ulcerative colitis. Surgery in Crohn's is for complications, not a cure.

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