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A 50-year-old man with Crohn's disease comes to the clinic for a routine follow-up appointment. He was diagnosed with Crohn's disease approximately 15 years ago. He is currently taking prednisone and sulfasalazine, and reports feeling well. He says he still occasionally has watery diarrhea, but denies fever, abdominal pain, or weight loss. He had a colonoscopy 1 year ago which demonstrated a few transmural inflammatory lesions in his descending colon. The most important management of this patient is
A. increase prednisone dose
B. increase sulfasalazine dose
C. prophylactic colectomy
D. surveillance barium enema every year
E. surveillance colonoscopy every year
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The correct answer is E. The most important recommendation for this patient is a surveillance colonoscopy every year in an effort to detect colon cancer early. Although the risk of colon cancer in Crohn's disease is much less than in ulcerative colitis, the risk increases significantly with involvement of the colon, and if the disease has been present for more than 10 years. This patient is at increased risk for colon cancer because he has had Crohn's disease for at least 15 years and has evidence of colon involvement. A colonoscopy is recommended because it is superior at detecting small lesions and biopsy of suspicious lesions can also be performed simultaneously.
An increase in prednisone dosage (choice A) is not indicated in this patient at this time. He reports feeling well and has only rare episodes of diarrhea. Medication adjustments should be made based on the patient's symptoms.
An increase in sulfasalazine dosage (choice B) is not indicated in this patient at this time. He reports feeling well and has only rare episodes of diarrhea. Medication adjustments should be made based on the patient's symptoms.
Prophylactic colectomy (choice C) is not indicated or recommended for this patient. Many patients with Crohn's disease who have extensive colitis undergo colectomy early in the course of disease to relieve persistent symptoms. This patient does not have severe symptoms nor does he have prior colonoscopy findings of dysplasia to warrant a colectomy. Prophylactic colectomy is often recommended for patients with ulcerative colitis with long standing colitis due to the increased risk of colon cancer.
Surveillance barium enema (choice D) is not the best recommendation for this patient. He has had Crohn's disease for over 10 years and is at increased risk for developing colon cancer. A barium enema is not as sensitive or specific for the detection of early colon cancer. Colonoscopy is recommended because it is superior at detecting small lesions and biopsy of suspicious lesions can also be performed simultaneously.
