CME Evaluation

CME Questions

This section provides a review. Mark each statement according to the factual material contained in this issue and the opinions of the authors. A score of 70% is required to qualify for CME credit.

Article One (pp. 67–74)

1. Which of the following is considered first-line therapy for mild, active Crohn disease?

   • Infliximab

   • Methotrexate

   • Azathioprine

   • Budesonide

2. Genetic or enzyme activity testing is recommended prior to initiation of which of the following medications?

   • Methotrexate

   • Mesalamine

   • Certolizumab

   • Azathioprine

3. A regimen consistent with combination therapy would include infliximab and

   • Mesalamine

   • Adalimumab

   • Metronidazole

   • Azathioprine

   • Budesonide

   Article Two (pp. 75–79)

4. Which of the following is incorrect?

   • Malnutrition is most easily defined as an albumin < 3.5 g/dl.

   • Elemental diets replenish nutritional imbalances and may induce remission of Crohn disease

   • Omega-3 fatty acids reduce proinflammatory leukotrienes and prostaglandins.

   • Omega-6 fatty acids produce proinflammatory products via the eicosanoid pathway.

5. Which of the following is correct?

   • Autoimmune dysfunction in Crohn disease is thought to be due to aberrant B-cell function.

   • Glucocorticoids are used for induction and maintenance of Crohn remission.

   • Adrenal insufficiency following glucocorticoid use may persist for up to 1 year.

   • Adrenal insufficiency occurs with daily use of prednisone 5 mg for 1 month.

6. Which of the following is true regarding smoking and Crohn disease?

   • Duration does not correlate with the extent of Crohn disease.

   • It is associated with increased anastomotic leaks following Crohn resection.

   • If stopped, smoking diminishes the recurrence of Crohn disease after resection.

   • Smoking aff ects Crohn recurrences after resection in men and women equally.

   Article Three (pp. 80–83)

7. All of the following appropriate indications for strictureplasty except

   • Patients who have undergone prior bowel resection of more than 100 cm in length

   • Multiple tandem strictures over a long segment of small bowel

   • Strictureplasty of a perforated fibrostenotic stricture

   • Stricture at the site of a previous ileocolonic anastomosis

8. The most common strictureplasty technique used for the management of fibrostenotic strictures in the setting of Crohn disease is

   • Finney

   • Heineke-Mikulicz

   • Michelassi

   • Jaboulay

9. Compared to conventional strictureplasty techniques, nonconventional strictureplasty techniques are

   • Associated with more complications

   • Less efficacious

   • Noninferior

   • Mostly used for short segment strictures

   Article Four (pp. 84–89)

10. What percentage of patients with Crohn disease has colonic involvement?

    • 20%

    • 40%

    • 60%

    • 80%

11. Compared with sporadic adenomas, nonadenoma DALM lesions

    • Are smaller lesions than sporadic adenomas

    • Are associated with a shorter duration of disease

    • Occur in younger patients than in those with sporadic adenomas

    • Typically stain positive for beta catenin and negative to P53

12. A 24-year-old woman with mouth ulcers presents with bloody diarrhea. Colonoscopy demonstrates severe indeterminate colitis and medical therapy with high-dose steroids and infliximab is initiated. Over the course of several weeks, the patient fails to improve and remains hospitalized. She has lost 20 pounds, her albumin is 1.9 mg/dl, and she is having 30 bowel movements daily. The most appropriate treatment is

    • Diverting loop ileostomy

    • Total colectomy with ileorectal anastomosis

    • Total colectomy with end ileostomy

    • Total proctocolectomy with ileoanal anastomosis

    Article Five (pp. 90–99)

13. A 48-year-old man with a 12-year history of Crohn disease presents to the office complaining of 3 days of increasing anorectal pain and fever. Exam in the officereveals multiple fleshy perianal skin tags, and tenderness over the left ischiorectal fossa without palpable fluctuance. Limited anoscopic exam reveals drainage of purulent material from a posterior midline internal opening. The most appropriate initial management is

    • Magnetic resonance imaging of the pelvis and referral for consideration of Remicade treatment

    • Computed tomography of the pelvis and operative drainage of ischiorectal abscess with mushroom catheter

    • Endorectal ultrasound and fistulotomy

    • Examination under anesthesia with abscess drainage and endoanal advancement flap

14. A 45-year-old woman with Crohn disease has a stable anterior midline fistula with an indwelling Seton. She wishes to have definitive surgical repair. Office anoscopy reveals no evidence of active anal or rectal inflammation. Endoanal ultrasound reveals a transsphincteric course of the fistula. The most appropriate management of this fistula is

    • Exam under anesthesia and ligation of intersphincteric fistula tract (LIFT) procedure

    • Fistulotomy with marsupialization of fistula tract

    • Endoanal advancement flap

    • Seton removal and subsequent initiation of immunomodulator treatment

15. A 25-year-old woman with active anorectal Crohn disease undergoes abscess drainage and subsequent placement of Seton in an anterior anoperineal fistula. The most appropriate next step in management includes

    • LIFT procedure

    • Fibrin glue injection

    • Endoanal advancement flap

    • Initiation of Remicade treatment

16. A 7-year-old boy with human immunodeficiency virus and Crohn disease presents with recurrent anorectal Crohn sepsis after initial abscess drainage and Seton placement with subsequent removal. He has undergone multiple abscess drainages and has issues with continence. He has been delinquent with follow-up for medical management of his Crohn disease. In the emergency room, he is found to have a white blood cell count of 15.7, and a blood pressure of 85/60, which responds to intravenous fluid boluses, and is started on parenteral antibiotics. The most appropriate next step in management is

    • Abscess drainage in the emergency room with subsequent initiation of Remicade

    • Proctectomy with permanent colostomy

    • Exam under anesthesia with wide debridement and advancement flap

    • Operative incision and drainage with diverting loop ileostomy

    Article Six (pp. 100–105)

17. In patients with severe acute or toxic Crohn colitis, the most appropriate operative procedure is

    • Segmental resection of the most grossly abnormal segment of the colon

    • Total abdominal colectomy with ileorectal anastomosis

    • Total abdominal colectomy with end ileostomy

    • Proctocolectomy with end ileostomy

18. In a patient with Crohn colitis limited to the sigmoid colon with an 8-cm benign sigmoid stricture and otherwise normal colon and rectum, which of the following operations is most appropriate?

    • Proctocolectomy with ileostomy

    • Proctocolectomy with ileal pouch anal anastomosis

    • Sigmoid colectomy with end colostomy

    • Sigmoid colectomy with colorectal anastomosis

19. In patients with Crohn disease of the colon and rectum (“pancolitis”) that is refractory to medical therapy, which of the following options should not be considered?

    • Segmental colectomy

    • Total abdominal colectomy with end ileostomy

    • Proctocolectomy with end ileostomy

    • Proctocolectomy with ileal pouch anal anastomosis

    Article Seven (pp. 106–111)

20. A 27-year-old woman with severe perineal fistulizing Crohn disease has failed medical management and requires a proctectomy. Her prealbumin is 6 and she is currently taking 80 mg/d of prednisone. The best strategy to minimize her risk of perineal wound complications is

    • Preoperative total parenteral nutrition and ileostomy diversion

    • Proctectomy with vertical rectus abdominis myocutaneous flap reconstruction

    • Preoperative antitumor necrosis factor antibody treatment

    • Proctectomy with primary closure

21. Of the following, which is considered a risk factor for perineal wound complications after proctectomy?

    • Cryptoglandular fistula

    • Prone jackknife position

    • Neoadjuvant radiation

    • Blood loss of 200 ml

22. Which of the following statements is correct regarding perineal wounds?

    • Although rare, chronic perineal wounds can undergo malignant degeneration.

    • Conservative wound care is the strategy of last resort.

    • Abstention from smoking is advised for at least 2 weeks preoperatively.

    • Obesity, neoadjuvant chemoradiation, and intraoperative bleeding have all been found to significantly lower the risk of perineal wound infection.

    Article Eight (pp. 112–121)

23. To determine the most optimal stoma site preoperatively, patients should be evaluated while

    • Standing, crouching, supine

    • Sitting, supine, crouching

    • Sitting, standing, supine

    • Sitting and supine only

24. Appropriate options for oral rehydration therapy for high output stoma include

    • Water

    • Soft drinks

    • Balanced glucose-electrolyte solutions

    • Tea

25. Vascular compromise to the stoma can be assessed using

    • Pediatric rigid proctoscope

    • Phlebotomy test tube and penlight

    • Flexible endoscope

    • All the above

    Article Nine (pp. 122–127)

26. Laparoscopy in Crohn disease is associated with

    • Shorter operative times

    • Improved cosmesis

    • Slower return of bowel function

    • Longer hospital stay

27. Laparoscopic surgery for Cohn disease has a longer learning curve laparoscopy for other benign and malignant colorectal disease. True or False?

    ANSWERS: You will receive a graded copy of your post-test along with the answer key when you are mailed your CME certificate from the Ochsner Clinic Foundation.