A 38 Years old patient was suffering from Crohn's disease for over 26 years. Stricturing and penetration of small & large bowel were performed. He was also diagnosed with the perianal disease(Complex fistula). So far conservatively the disease has been managed. TNF Agents - Developed Serum Sickness-? Antibodies to anti-TNF Agents Azathioprine -> Anemia Responded to vendolizumab initially -> Post Covid exacerbation of symptoms - not responding to vendolizumab + Steroid Endoscopy: not able to cross sigmoid stricture (2 Years) MRI Pelvis 01.06.21 Complex low rectal fistula with translevator course and significant inflammatory changes Small intersphincteric abscess Sigmoidoscopy 01.06.21 - Multiple deep irregular ulcers and polypoidal lesions(? Pseudopolyps) with friable mucosa causing luminal narrowing. Scope could not be negotiated beyond. Bx - Moderately active inflammation with mucoid lymphoid hyperplasia in a know case of Crohn's disease March 2020 July 2020 June 2020 At Present, Since 15 Days: Watery stools- 15/20 days - Small volume- no blood/ mucus Bloating Weight loss 8Kg in 15 days H/o repeated admissions for similar complaints for 3 months (Vedolizumab restated post covid) 22.07.21 Hb - 11.1 TLC- 12000 Plat 3.4 lakhs Alb - 4.1 Next Option?? Kindly share us your comment

A 15 month old infant had symptoms like Chronic diarrhea. On blood report analysis it was evaluated that the infant has Anemic conditon, Thrombocytosis, High ESR ( Erythrocyte Sedimentation Rate ) and CRP (C-Reactive Protein). Further to confirm the diagnosis Colonoscopy for performed which resulted in Terminal Ileum Small ulcers. UGIE normaland colon were normal, MR Enterography was ileum. To confirm the further the stage of ulcer biopsy of ileum is sent and awaiting for the result.

• Symptom onset – June 2020 • Diarhoea, intermittently streak blood+, mucous+ • Treated with antibiotics – syp. Taxim & metronidazole for ~3-4 months • Elsewhere – Stool : E. histolytica cysts+ => treated with metrogyl Oct 2020 (AIG) On evaluation • Presented with bloody diarrhoea & lethargy • CBC – 7.8 / 26500 (N 77, L 13) / 5.3 lac • Hs-CRP – 13.2 • Procalcitonin – 0.05 • Colonoscopy – Superficial ulceration & erythema with white exudates and loss of vascularity in entire colon --- Pancolitis • Biopsy – Moderate active inflammation with crypt disarray -? Infective /? IBD • Treated with antibiotics --- TLC subsided and pt started on Rowasa sachets & mesacol suppositories • Symptomatically better Current episode • High grade fever spikes, Bloody diarrhoea (5-6/day), lethargy and increased sleepiness – since 12-15 days • USG abdomen – Mild assymetric mural thickening in descending, sigmoid colon, paracolic subcentrimetric LN & mesenteric LN- ?inflammatory • CECT abdomen – Long segment wall thickening with mucosal enhancement in Ac, TC, DC and sigmoid with prominent vessels & pericolic LN -- ?inflammatory / ?infecitve • X-ray chest – Normal • Widal – 1:20 titres (negative) • Sr. procalcitonin – • Blood cultures – • Urine cultures – • Stool cultures – • Sigmoidoscopy – Multiple superficial ulcers with loss of vascularity in rectum & deep ulcers with whitish exudates in sigmoid Issues • Paediatric IBD – UC • High TLC & high grade fever spikes • Initially started on piptaz • Changed to meropenem since 29/12/2020 • ?Infectious etiology / vs Inflammation due to IBD

• 2014 --- Increased frequency of SAIO • Surgery – (15/01/2014): Lap CCx + ileocaecal & ileal resection with ileo-ascending anastomosis. Op findings – Thin walled distended GB with multiple calculi – Long segment distal ileal stricture (2 feet) with fat creeping – Stricture extending till IC junction – Omentum densely adherant to caecum & abdominal wall Complicated (21/01/2014) --- Re-exploration – Ascending colonic gangrene near anastomotic site with fecal peritonitis (Rt lower abdomen) June 2014 • Restoration surgery for ileo-colonic continuity + adhesiolysis • Biopsy – benign stricture with focal mucosal ulcerations with foci of fissure like ulceration with mild crypt disarray, submucosal fibrosis & transmural inflammation with focal fat wrapping, no granulomas --- Crohn’s disease > CMUSE • Started on 5-ASA and Azathioprine --- Continued till 2020 • Regular follow-up & treatment compliant • Minor flares over past 6 yrs • No steroids / biologics • Symptomatic since Oct 2020 --- abdominal pain, bilious vomiting's – Recurrent SAIO • CBC, RFT, LFT – Normal • Fecal calprotectin - 384 mg/kg • Colonoscopy - circumferential ulceration at anastomotic site but no narrowing, aphthous ulcers with mucosal edema at neo-terminal ileum, no stenosis • CECT – Dilated jejunal loops, collapsed loops of terminal ileum with narrowing in neo-terminal ileum -? due to adhesions 18/12/2020 29/12/2020