A 50-year-old woman presents with new onset bloody diarrhea and weight loss. Colonoscopy reveals acute colitis from 20 to 40 cm above the anal verge. The rest of the colon and terminal ileum are normal.. Biopsies of the colonic mucosa show acute inflammation with crypt abscesses. A giant cell granuloma is identified on one of the slides. Despite 48 hours of medical therapy with intravenous antibiotics and systemic corticosteroids, the patient has worsening abdominal pain, without distention, and bloody diarrhea. The most appropriate operative management of this patient would be:

A 31-year-old woman with ulcerative colitis presents to your office to discuss the possibility of an ileal pouch–anal anastomosis (IPAA). She underwent a total abdominal colectomy with end ileostomy creation about a year ago for medically refractory ulcerative colitis. She has gained back 20 pounds and feels well. However, she does not want to live with an ostomy for the rest of her life. You discuss the procedure in detail, including the possible complications. What should you tell her is the most common complication following IPAA?

A 33-year-old man with a 12-year history of ulcerative colitis experiences a flare of his disease. Colonoscopy demonstrates moderately inflamed mucosa with scattered ulcers and friability. The disease activity extends from the rectum to the mid-descending colon. Biopsies show features consistent with active ulcerative colitis, but multiple biopsies also demonstrate atypia and mild dysplasia. The best management would be

A 40-year-old man with Crohn disease with recurrent partial small bowel obstructions is diagnosed with multiple small bowel strictures on magnetic resonance enterography. He looks well and has no significant weight loss. His surgical history includes an ileocecectomy. He is taken for an exploratory laparotomy. At the time of surgery, three strictures in the midileum, all between 5 and 7 cm in length are found. More than 25 cm of normal intestine lies between the involved segments. How should the surgeon proceed?

A 26-year-old woman presents to your office for a follow-up appointment to discuss ileal pouch–anal anastomosis (IPAA) after her total abdominal colectomy with end ileostomy for medically refractory ulcerative colitis. She is 6 months out from surgery and has recovered very well. What would be an absolute contraindication to IPAA for this patient?

A 29-year-old man has been admitted to the internal medicine service with an acute flare of ulcerative colitis for the past 6 days. He has been receiving IV methylprednisolone and was started on infliximab 72 hours ago with no improvement. The surgery team is consulted and decides to take him to the operating room for a resection after discussion with the patient. What principle of surgical management of severe-to-fulminant chronic ulcerative colitis would the surgeon keep in mind during this patient's operative repair?

A 23-year-old man just underwent extensive work-up including colonoscopy and was diagnosed with Crohn disease. He is asking you about future screening for colorectal cancer. His father was diagnosed with colon cancer at the age of 70. At what age would you recommend that screening begin for your patient?

A 47-year-old man with ulcerative colitis presents to your office after a screening colonoscopy found an area of high-grade dysplasia in the cecum 6 cm from the ileocecal valve. He is asymptomatic and has had great control of his ulcerative colitis since starting infliximab 5 years ago. What treatment would you recommend for this patient?

A 22-year-old man presents with 3 days of worsening abdominal pain, upwards of 10 bowel movements a day, and new onset of bright red blood per rectum. He is febrile to 38.4ºC, tachycardic but normotensive, and has an erythrocyte sedimentation rate (ESR) of 35 mm/hr. Abdominal imaging does not reveal any colonic dilation. The patient has no evidence of peritonitis on examination, but he does have moderate tenderness. He does not have any significant medical history and has never had these symptoms before. He is taken for a colonoscopy. What would you expect a colonoscopy to reveal in this patient?

A 29-year-old woman presents with 3 months of diarrhea, abdominal pain, weight loss, and perineal drainage from a tender indurated area anterior to the rectum. A colonoscopy shows patchy areas of inflammation in the rectum and terminal ileum. What makes a diagnosis of Crohn disease more likely than ulcerative colitis in this woman?

A 47-year-old woman underwent a total proctocolectomy with ileal pouch–anal anastomosis 2 years ago. She now presents to the emergency department with complaints of increased stool frequency and urgency over the past 2 weeks. She has noticed some bleeding with the passage of stool. She states that it is intermittent but bright red in color. Laboratory studies are insignificant for abnormalities. The woman has no abdominal tenderness to palpation. Previous routine endoscopies of her residual anal mucosa showed no signs of dysplasia or malignancy. What is the best initial treatment for this woman?

A 24-year-old man presents to surgery clinic with a perirectal abscess and fever. He also reports a history of diarrhea and 25-lb weight loss over the past 6 months. What is the next best step in the management of this patient?

A 55-year-old man with history of Crohn disease and no previous abdominal surgeries presents to the hospital with a 3-day history of obstipation and worsening abdominal distention. Workup reveals a single stricture in his right colon. He is initially treated with bowel rest, nasogastric decompression, IV fluids, and steroids; however, he fails to improve after several days. What is the next best option?

A 55-year-old woman with known ulcerative colitis that is poorly managed with biologics presents to the emergency department with diffuse abdominal pain. On physical examination, she is tachycardic and has diffuse abdominal tenderness. Her white blood cell count is significant for left shift and it is elevated at 17,000/µL. Abdominal x-rays show a dilated colon with the cecum measuring 14 cm in diameter and the mid transverse colon measuring 9 cm. You decide to admit her to the surgical floor with intravenous antibiotics and fluid resuscitation. Twelve hours later, her pain is worsening and she appears in distress. Her creatinine is now elevated at 1.4 mg/dL, her lactate is 4.0 mmol/L, and her blood gas shows a severe metabolic acidosis. You are contemplating an emergent operation. Which is the most appropriate operation for her present diagnosis?

A 72-year-old woman who underwent a hysterectomy 30 years ago presents with fecaluria. A CT scan reveals thickening of the sigmoid colon and air in the bladder. She is hemodynamically stable. What is the next step in treatment?

A 49-year-old woman with a long-standing diagnosis of ulcerative colitis presents to the emergency department with crampy abdominal pain, bloody bowel movements 10 times daily, fevers, chills, and eating intolerance. She is febrile, tachycardic, and tender but not peritoneal on examination. Her hemoglobin is 9.8 g/dL. She reports she is not currently taking any medications, but notes that she was on aminosalicylates many years ago but stopped taking them due to lack of symptoms. Her last colonoscopy was 6 months ago, and it revealed no active inflammation or dysplasia. What is the most appropriate initial medical management for this patient?

A 75-year-old woman with history of heart disease, renal insufficiency, and active Crohn's disease presents with rectal bleeding and is found to have a T3N1M0 mid-rectal adenocarcinoma. She is considered for curative treatment. Given her comorbidities, which of the following strategies may improve her outcome?