A 17-year-old girl comes to the physician for a scheduled colonoscopy. She was diagnosed with familial adenomatous polyposis at the age of 13 years. Last year, her flexible sigmoidoscopy showed 12 adenomatous polyps (< 6 mm) that were removed endoscopically. Her father and her paternal grandmother were diagnosed with colon cancer at the age of 37 and 39 years, respectively. The patient appears nervous but otherwise well. Her vital signs are within normal limits. Examination shows no abnormalities. A complete blood count and serum concentrations of electrolytes, urea nitrogen, and creatinine are within the reference range. A colonoscopy shows hundreds of diffuse 4–9 mm adenomatous polyps covering the colon and > 30 rectal adenomas. Which of the following is the most appropriate next step in management?

Proctocolectomy with ileoanal anastomosis

CT scan of the abdomen with contrast

Folinic acid (leucovorin) + 5-Fluorouracil + oxaliplatin therapy

A 32-year-old man comes to the emergency department because of recurrent episodes of vomiting for 1 day. He has had over 15 episodes of bilious vomiting. During this period he has had cramping abdominal pain but has not had a bowel movement or passed flatus. He does not have fever or diarrhea. He was diagnosed with Crohn disease at the age of 28 years which has been well controlled with oral mesalamine. He underwent a partial small bowel resection for midgut volvulus at birth. His other medications include vitamin B12, folic acid, loperamide, ferrous sulfate, and vitamin D3. He appears uncomfortable and his lips are parched. His temperature is 37.1°C (99.3°F), pulse is 103/min, and blood pressure is 104/70 mm Hg. The abdomen is distended, tympanitic, and tender to palpation over the periumbilical area and the right lower quadrant. Rectal examination is unremarkable. A CT scan of the abdomen shows multiple dilated loops of small bowel with a transition zone in the mid to distal ileum. After 24 hours of conservative management with IV fluid resuscitation, nasogastric bowel decompression, promethazine, and analgesia, his condition does not improve and a laparotomy is scheduled. During the laparotomy, two discrete strictures are noted in the mid-ileum, around 20 cm apart. Which of the following is the most appropriate next step in management?

Strictureplasty of individual strictures

Small bowel resection with ileostomy

Abdominal closure and start palliative care

Small bowel resection and primary anastomosis

A 22-year-old man presents to the emergency department with abdominal pain. The patient states that he has had right lower quadrant abdominal pain for "a while now". The pain comes and goes, and today it is particularly painful. The patient is a college student studying philosophy. He drinks alcohol occasionally and is currently sexually active. He states that sometimes he feels anxious about school. The patient's father died of colon cancer at the age of 55, and his mother died of breast cancer when she was 57. The patient has a past medical history of anxiety and depression which is not currently treated. Review of systems is positive for bloody diarrhea. His temperature is 99.5°F (37.5°C), blood pressure is 100/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is within normal limits. Abdominal exam reveals diffuse tenderness. A fecal occult blood test is positive. Which of the following is the most likely diagnosis?

Inflammatory bowel disease (IBD)

A 32-year-old man with Crohn disease is brought to the emergency department after he fainted at work. He says that he has been feeling increasingly fatigued and weak over the last several weeks though he has not previously had any episodes of syncope. On presentation he is found to be pale and agitated. A panel of lab tests is performed showing the following: Hemoglobin: 10.2 g/dL Hematocrit: 30.1% Leukocyte count: 9,900 cells/mm^3 with normal differential Platelet count: 290,000/mm^3 Mean corpuscular volume: 118 µm^3 Elevated homocysteine level Normal methylmalonic acid level Which of the following mechanisms explains how Crohn disease may have contributed to this patient's symptoms?

Release of acute phase proteins

A 25-year-old man presents to the emergency department for severe abdominal pain. The patient states that for the past week he has felt fatigued and had a fever. He states that he has had crampy lower abdominal pain and has experienced several bouts of diarrhea. The patient states that his pain is somewhat relieved by defecation. The patient returned from a camping trip 2 weeks ago in the Rocky Mountains. He is concerned that consuming undercooked meats on his trip may have caused this. He admits to consuming beef and chicken cooked over a fire pit. The patient is started on IV fluids and morphine. His temperature is 99.5°F (37.5°C), blood pressure is 130/77 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% on room air. Laboratory studies are ordered and are seen below. Hemoglobin: 10 g/dL Hematocrit: 28% Leukocyte count: 11,500 cells/mm^3 with normal differential Platelet count: 445,000/mm^3 Serum: Na+: 140 mEq/L Cl-: 102 mEq/L K+: 4.1 mEq/L HCO3-: 24 mEq/L BUN: 24 mg/dL Glucose: 145 mg/dL Creatinine: 1.4 mg/dL Ca2+: 9.6 mg/dL Erythrocyte sedimentation rate (ESR): 75 mm/hour Physical exam is notable for a patient who appears to be uncomfortable. Gastrointestinal (GI) exam is notable for abdominal pain upon palpation. Ear, nose, and throat exam is notable for multiple painful shallow ulcers in the patient's mouth. Inspection of the patient's lower extremities reveals a pruritic ring-like lesion. Cardiac and pulmonary exams are within normal limits. Which of the following best describes this patient's underlying condition?

Transmural granulomas in the bowel

p-ANCA positive autoimmune bowel disease

Gram-negative microaerophilic organism

Surgical management in IBD for USMLE Step 2 CK: High-Yield Internal Medicine Lessons

Indications for Surgery - The Cutting Edge

Ulcerative Colitis (UC) - Curative

Emergent:
- Toxic megacolon (>6 cm colonic dilation + toxicity)
- Fulminant colitis, perforation, uncontrolled hemorrhage
Elective:
- Medically refractory disease
- Dysplasia or colorectal cancer (CRC)
- Growth retardation in children

Crohn's Disease (CD) - Not Curative; for Complications

Indications:
- Bowel obstruction from fibrotic strictures (most common)
- Intra-abdominal abscess
- Fistulae (e.g., enterovesical)
- Medically refractory disease

⭐ Smoking is the strongest modifiable risk factor for post-operative recurrence in Crohn's disease.

Crohn's Disease: Indications for Surgical Management

Ulcerative Colitis Surgery - The Curative Colectomy

Unlike Crohn's, surgery is curative for UC, removing all diseased colonic and rectal mucosa.
Standard of Care: Total Proctocolectomy (TPC) with Ileal Pouch-Anal Anastomosis (IPAA).
- The ileal pouch (e.g., "J-pouch") acts as a neorectum.
- Avoids a permanent ileostomy, preserving continence.
- Typically performed in 2 or 3 stages, especially in acutely ill patients on high-dose steroids.

3-Stage J-Pouch Surgery for IBD

Key Complications:
- Anastomotic leak, pelvic sepsis
- Pouchitis & Cuffitis
- Small Bowel Obstruction
- Reduced female fertility (due to pelvic adhesions)

⭐ Pouchitis is the most common long-term complication, affecting up to 50% of patients. It presents with ↑ stool frequency, urgency, and cramps. Treat with antibiotics (Metronidazole or Ciprofloxacin).

Crohn's Disease Surgery - Respect the Bowel

Not Curative: Surgery manages complications, not the underlying disease. The core principle is bowel conservation.
Primary Indications:
- Fibrotic strictures causing obstruction (most common)
- Intra-abdominal abscesses
- Fistulae (e.g., enterovesical, enterocutaneous)
- Refractory hemorrhage or free perforation
- Failure of maximal medical therapy
- Dysplasia or cancer
Surgical Approaches:
- Strictureplasty: Widens narrowed segments without resection (e.g., Heineke-Mikulicz). Preserves bowel length.
- Limited Resection: Removal of only the grossly affected bowel segment.

⭐ Post-operative recurrence is high (~60% endoscopic recurrence at 1 year), most commonly occurring in the neoterminal ileum, just proximal to the anastomosis.

Post-Op Complications - The Aftermath

Anastomotic Recurrence (Crohn's Disease)
- Common at the site of ileocolonic anastomosis.
- Presents with obstruction, fistulas, or abscesses.
- Requires surveillance endoscopy for early detection.
Pouchitis & Cuffitis (UC after IPAA)
- Pouchitis: Inflammation of the ileal pouch. Presents with cramps, ↑ frequency, urgency.
  - Tx: Metronidazole or Ciprofloxacin.
- Cuffitis: Inflammation of the residual rectal cuff.
General Surgical Risks
- Early: Anastomotic leak, sepsis, wound infection.
- Late: Adhesions (→ SBO), hernias, short bowel syndrome.

⭐ Pouchitis is the most common long-term complication after an IPAA for UC, affecting up to 50% of patients.

High‑Yield Points - ⚡ Biggest Takeaways

Surgery is curative in Ulcerative Colitis (total proctocolectomy) but palliative in Crohn's disease, which is reserved for complications.

Urgent indications for UC surgery include toxic megacolon, perforation, or massive hemorrhage; elective reasons include dysplasia or refractory disease.

Crohn's surgery addresses strictures, fistulas, and abscesses. The most common procedure is an ileocecal resection.

Total proctocolectomy with IPAA is the standard restorative surgery for UC.

Pouchitis is a common complication of IPAA.

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