Background Illness:   2011 Initially diagnosed as Ulcerative colitis (pancolitis) and started on Mesalamine.   2012 ·       Developed pancreatitis – mild interstitial, ? 5ASA-induced. ·       She received a course of steroids for active disease and experienced flare with tapering of steroids. ·       July - Underwent sub-total colectomy with loop ileostomy ·       September – Underwent proctectomy with IPAA ·       December – ileostomy closure ·       On POD6 after ileostomy closure, the patient developed a pouchovaginal fistula, hence diversion ileostomy was done.   2013 à  ·       May - Pouchovaginal fistula repair done with labial flap. ·       November – Ileostomy reversal done.   December 2013 to Dec 2023 ·       Uneventful ·       Stool frequency: 4 to 5 per day, Bristol 5 in consistency, No mucus or blood. ·       Weight gain of 12 kg   History of presenting complaints:   From 2024, Jan ·       Complained of Increased stool frequency, occasionally associated with blood and recurrent oral ulceration ·       Oral examination revealed the presence of ulcers on both soft and hard palate ·       A Pouchoscopy was done, and the findings were as follows (figure 1) Fistulous opening just above the anal verge Diffuse oedema of the pouch with superficial ulcerations Changes of cuffitis Neo terminal Ileum - normal.   Diagnosis: Post-colectomy with IPAAPouchovaginal fistula s/p repair with Martius (labial) flap Perianal fistula Recurrent oral ulceration ?Oral Crohn’s Pouchitis (PDAI – 10)   The course of illness: The patient was initiated on a course of antibiotics (ciprofloxacin and metronidazole) after 8 weeks of antibiotics there was no improvement in disease activity (PDAI-8)   Given persistent symptoms on antibiotics, development of fistula, and persistent oral ulceration, a “Crohn’s like disease of pouch” was suspected. Hence a decision was taken to start the patient on Infliximab.   May 2024 ·       After two doses of infliximab, there was an improvement in symptoms of pouchitis, but the patient again presented with Odynophagia. ·       Oral Examination showed persistent oral ulcers involving the buccal mucosa, soft and hard palate. ·       An Upper GI Endoscopy showed the presence of erosions throughout the oesophagus, more evident in the lower and middle 1/3rd and the mucosa was easily sloughing off from the submucosal layer. (Figure 2) The stomach and duodenum were normal. With a suspicion of viral esophagitis, upper GI CD. A biopsy was taken from the upper, mid and lower third of the oesophagus. ·       Because of painful ulceration in the background of immune suppression, oral candidiasis was suspected and the patient was started on fluconazole for 2 weeks, without response. ·       The initial Biopsy of the Esophagus showed focal areas of stripping of mucosa from the basal layer and breaks in oesophagal mucosa with no evidence of inflammation or inclusion bodies. (Figure 3)   Workup for recurrent painful oral ulceration: ·       Tissue for HSV, CMV PCR –  Negative ·       Oral swab for fungal c/s – Negative ·       Autoimmune markers: ANA (IF) – Negative, dsDNA – Negative. ·       Anti Desmoglein 1 and 3 antibodies: negative ·       Pathergy test – Negative ·       Procalcitonin –negative ·       ESR-21   With no response to infliximab and antifungal and persistent odynophagia, the patient was initiated on oral steroid (prednisolone) 40mg. 1 week:  post initiation of steroid, the patient has a reduction in dysphagia. Was able to tolerate oral liquids. 2 weeks: Repeat Upper GI endoscopy was done which showed no erosions in the upper and mid oesophagus and ongoing healing in the lower one-third of the oesophagus. (Figure 4) There was a significant reduction in oral ulcerations.   Final Diagnosis:   Post-colectomy with IPAAPouchovaginal fistula s/p repair with Martius (labial) flap Perianal fistula Chronic Antibiotic refractory pouchitis Recurrent oral ulceration Esophagitis desiccans superficialis. s/p 2 doses of Remicade On Tapering doses of prednisolone.

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