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Difficulty: HardGastroenterology and Hepatology

A 2828-year-old man is evaluated in the hospital on day 55 of an admission for a severe flare of ulcerative colitis. On admission, stool studies were negative for Clostridioides difficile toxin and routine enteric pathogens, and he was started on intravenous methylprednisolone. Despite 55 days of high-dose corticosteroid therapy, he continues to have 1010 to 1212 bloody bowel movements daily accompanied by abdominal cramps. Vital signs show a temperature of 38.3∘C38.3^\circ\text{C} (100.9∘F100.9^\circ\text{F}), heart rate of 115115/min, and blood pressure of 110/70 mm Hg110/70\text{ mm Hg}. Physical examination reveals a non-distended abdomen with left lower quadrant tenderness, but no guarding or rebound. Laboratory studies show a hemoglobin of 9.2 g/dL9.2\text{ g/dL}, leukocyte count of 14,000/mm314,000/\text{mm}^3, and C-reactive protein of 65 mg/L65\text{ mg/L}. Abdominal radiography reveals colonic mucosal thickening without colonic dilation. Which of the following is the most appropriate next step in management?

  1. Flexible sigmoidoscopy with biopsyAnswer
  2. B
    Intravenous infliximab therapy
  3. C
    Total abdominal colectomy with end ileostomy
  4. D
    Cytomegalovirus serologic testing
  5. E
    Intravenous piperacillin-tazobactam

Answer

Flexible sigmoidoscopy with biopsy
The correct answer is flexible sigmoidoscopy with biopsy. This patient has steroid-refractory severe ulcerative colitis. Before escalating to salvage medical therapies such as infliximab or cyclosporine, it is imperative to rule out superimposed cytomegalovirus (CMV) colitis. CMV frequently reactivates in the inflamed colonic mucosa of immunosuppressed patients (such as those on high-dose steroids). If a biologic agent is given to a patient with unrecognized CMV colitis, it can lead to toxic megacolon, perforation, or systemic viral dissemination. Flexible sigmoidoscopy with mucosal biopsy (for histopathology and immunohistochemistry) is the diagnostic test of choice to identify CMV inclusion bodies.

Step-by-Step Solution

1
Analyze the patient's clinical trajectory
The patient has severe ulcerative colitis that has not improved after 5 days of intravenous corticosteroids.
Establishing the diagnosis of steroid-refractory ulcerative colitis dictates the need for a change in management strategy.
2
Evaluate for complications of severe colitis
The abdominal X-ray shows no colonic dilation, and the physical exam lacks peritoneal signs.
This rules out toxic megacolon and perforation, meaning emergent surgical intervention is not currently indicated.
3
Identify the next required diagnostic step before escalating medical therapy
Superimposed cytomegalovirus (CMV) colitis must be excluded via flexible sigmoidoscopy with biopsy.
Patients on high-dose corticosteroids are at high risk for CMV reactivation in the colon. Initiating salvage immunosuppressants (e.g., infliximab, cyclosporine) in the presence of active CMV colitis can lead to severe, potentially fatal viral dissemination.

Key Concept

In patients with severe ulcerative colitis who are refractory to intravenous corticosteroids, flexible sigmoidoscopy with biopsy should be performed to evaluate for superimposed cytomegalovirus (CMV) colitis before initiating salvage medical therapies.
Estimated Time:1m 30s
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Topics

Gastroenterology and Hepatology

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