Diagnosis: Crohn's disease, diagnosed 2008 (records variably date onset 2008-2013), presenting with intermittent diarrhea, hematochezia, and abdominal pain; initially treated as suspected ulcerative colitis before Crohn's disease was established.1

IBD Phenotype: CD Location L1 (ileal); CD Behaviour B2 (stricturing).2

Active Medications:
1. Filgotinib 200 mg PO daily (open-label extension clinical trial for Crohn's disease); started 20191

IBD-Related Surgeries / Hospitalizations:
- 2014: Ileocolic resection — resection of approximately 80-100 cm of diseased terminal ileum plus cecum, ileocecal valve, appendix, and proximal ascending colon for obstructive symptoms from severe ulcerating and stricturing Crohn's disease; laparoscopic attempt converted to open midline laparotomy; primary stapled anastomosis; postoperative ileus requiring NG tube, recovered quickly.3

Extraintestinal / Associated IBD Conditions:
- 2021-2024: Arthritis/arthralgia (peripheral, IBD-associated) — recurrent arthralgias reported at serial study visits; joint swelling/pain related to IBD reported on the most recent symptom score sheet; no specific joints, imaging, or treatments documented.4
- 2019: Possible inflammatory arthralgia — lower back and knee pain, worse at rest and better with activity, in the context of active Crohn's disease; no objective imaging or specific treatments documented.5
- 2017: Questioned sacroiliitis — chronic low back pain with morning stiffness; pelvis x-ray showed no radiographic evidence of inflammatory sacroiliitis; no confirmed axial spondyloarthritis diagnosis.4
- 2017-2021: Nephrolithiasis — listed as an IBD extraintestinal manifestation; historical left renal colic with passage of a calcium oxalate stone and recent stone-removal procedure; reported as ongoing adverse event at a 2021 study visit.4

Past Medical History:
- 2015: Right shoulder hibernoma excision — pathology negative for malignancy.6
- December 2016: Type 2 diabetes mellitus — no documented nephropathy, retinopathy, neuropathy, coronary artery disease, cerebrovascular disease, or peripheral vascular disease.7
- December 2016: Dyslipidemia / hypertriglyceridemia7
- 2012: Obstructive sleep apnea — using CPAP.8
- Obesity (BMI >35)9
- Hypertension10
- Fatty infiltration of the liver11
- Cholelithiasis12
- Colonic diverticula13
- Incidental Meckel's diverticulum14
- Small fat-containing left inguinal hernia; self-reducing incisional (abdominal wall) hernia at the surgical incision site12
- Small bladder diverticulum15
- Vitamin B12 deficiency; chronic anemia; iron deficiency history8
- Hypogonadism16
- Chronic back pain and herniated disc8
- Insomnia8
- Herpes zoster ophthalmicus17
- Eczema18
- Appendectomy19
- COVID-19 infections x3, all mild20

Prior IBD Therapies:
- 2019 to present: Filgotinib (Jyseleca) 200 mg PO daily, open-label extension of a clinical trial (JAK inhibitor); symptomatic improvement after starting with provider assessments of symptomatic remission at serial visits, but persistent endoscopic ileal activity (2020 colonoscopy neoTI Rutgeerts i4, SES 8; 2022 colonoscopy stable ileal disease); temporarily held 2021-Apr-18 for COVID-19 infection and restarted 2021-May-16; documented plan for 4-week washout prior to a further study randomization; ongoing.21
- ~2018-Sep to 2019-Apr: Budesonide (Entocort) 9 mg PO daily (3 mg capsules x3); inadequate response — moderately active disease despite budesonide; last fill 2019-Apr-11; stopped around filgotinib trial start (stop not documented).22
- ~2018-Sep to ~2018-Nov: No ongoing IBD-directed maintenance therapy documented (vedolizumab washout before clinical trial enrolment; budesonide only as bridge).23
- 2017-Nov to 2018-Sep: Vedolizumab (Entyvio) 300 mg IV (loading at Weeks 0, 2, 6, then q8 weeks); initial symptomatic improvement (more formed stools, some improvement in frequency), then secondary loss of response; interval shortened to q4 weeks in 2018-Apr with no symptomatic improvement despite escalation; stopped 2018-Sep, followed by washout.24
- 2017-Nov to 2018-Sep: Methotrexate 2.5 mg PO tablets, 10 tablets once weekly (started with prednisone for induction, then as combination with vedolizumab to prevent antibody formation); ongoing as of 2018-Sep; subsequent course/stop not documented.25
- 2017-Nov to ~2018: Prednisone for induction together with methotrexate after the Mongersen trial stopped; no stop date or response documented.26
- 2017-Oct to 2017-Nov: No ongoing IBD-directed maintenance therapy documented (off all therapy after trial stop; vedolizumab or ustekinumab discussed as future options).27
- ~2016-Nov to 2017-Oct-19: Mongersen (GED-0301) 160 mg PO daily via Phase 3 clinical trial; partial response — resolution of rectal bleeding, reduced stool frequency (6-9/day to 3-6/day), less urgency; no endoscopic improvement (2017-Feb colonoscopy essentially unchanged from baseline); stopped 2017-Oct-19 when the trial was terminated early for lack of efficacy on interim analysis (no safety issue).28
- 2014-Jul to 2016: Adalimumab (Humira) 40 mg SC weekly (restarted after 2014-Mar endoscopy showed active ileitis); initial clinical improvement, then secondary loss of response — persistent/severe ileitis on 2015 endoscopy, symptoms ongoing at 2016-Feb visit; dose escalated to 80 mg SC weekly 2016-Apr; stopped 2016 due to inadequate response (not working).14
- 2013-Dec to 2014-Jul: No ongoing IBD-directed maintenance therapy documented (all therapy discontinued at 2013-Dec ileal resection; slow postoperative improvement).1
- 2013-May to ~2013-Jul: Prednisone course; steroid-dependent — diarrhea resolved completely on prednisone but returned during taper; adalimumab dose escalated concurrently.1
- 2013-Jan to 2013-Dec: Adalimumab (Humira) (within-class anti-TNF switch after infliximab loss of response); dose escalated to weekly in 2013-Jul; inadequate response; stopped after 2013-Dec ileal resection.1
- 2012-Apr to ~2012: Azathioprine (Imuran) 275 mg PO daily (restart after flare); intolerance — severe GI side effects; stopped.1
- 2012 to 2013-Jan: Methotrexate 7.5 mg PO weekly with folic acid (combination with infliximab); remained clinically symptomatic throughout 2012; patient-initiated discontinuation in 2013-Jan.1
- 2011-Oct to 2013-Jan: Infliximab (Remicade) monotherapy; secondary loss of response — inflammatory markers remained elevated with persistent loose stools and abdominal pain; interval shortened to q6 weeks in 2012; switched to adalimumab.29
- 2011-May to ~2012: Azathioprine (Imuran) titrated to target dose 300 mg/day; initial clinical responder (improving dramatically by 2011-Jul, though persistent loose stools 2/day and intermittent abdominal discomfort); stopped prior to 2012-Apr flare (exact stop date not documented).1
- 2010: 5-ASA therapy (initial presentation as suspected ulcerative colitis); partial response — bowel movements improved from 12/day to 4/day.1

Social History: Ex-smoker since age 13-14, quit approximately 12 years ago (as of 2016; most recent intake documents non-smoker). Does not consume alcohol (earlier records note minimal intake). No recreational drug use other than marijuana, which he uses at night to manage insomnia (sleeps 6 hours/night); no IV drug use. Works as a manager, seasonal full time (44 hours/week) with winters off; work entails some walking and he does not exercise; employment not particularly limited by his disease. Married with children; born in Canada; OHIP coverage with a Group Benefit Plan that approved ongoing biologic coverage.8

Family History: No family history of IBD or colon cancer. Father: angina, diabetes, prostate cancer, sleep apnea. Mother: diabetes. Paternal grandfather: angina, diabetes; paternal grandmother: cancer (type unspecified). Maternal grandfather: diabetes, arthritis, lung disease from mining; maternal grandmother: leukemia. Family history of cardiovascular disease also noted in the context of risk assessment.4

Endoscopy History:
- 2022-02-28 Colonoscopy: Anastomosis widely patent with ulceration at the anastomosis; ongoing neoterminal ileum inflammation with >5 small and medium ulcers (some >1 cm); colon and rectum normal; neoTI Rutgeerts i4, ileal SES-CD 7, total SES-CD 7.30
- 2020-03-05 Colonoscopy: Entire colon normal; anastomosis widely patent; neoterminal ileum involved with a moderately significant inflammatory process of small and medium ulcers and diffuse erythema; ileal SES 8, Rutgeerts i4.31
- 2018-12-03 Colonoscopy: Colon entirely normal; neoterminal ileum diffusely inflamed with numerous large ulcers (some >2 cm); ileal SES-CD 9, Rutgeerts 4.32
- 2017-02-05 Colonoscopy: Colon normal; anastomosis mildly inflamed with aphthous ulcerations, not narrowed; neoterminal ileum diffusely inflamed with aphthous ulcerations; Rutgeerts i3, SES-CD 7 (exam limited by poor preparation and sigmoid looping).33
- 2016-11-09 Colonoscopy and ileoscopy: Colon normal; anastomosis widely patent; neoterminal ileum (7-10 cm) diffuse mucosal erythema with scattered ulcers; Rutgeerts i3.34
- 2016-07-18 Colonoscopy: Colon normal; ~10-15 cm of neoterminal ileum examined with marked aphthous ulcerations; SES-CD 7, Rutgeerts i3; no narrowing or stenosis.35
- 2015-05-13 Colonoscopy: Colon entirely normal; significant ileitis with diffuse redness and multiple ulcerations.36
- 2015 Colonoscopy: Ileal scars (date partially legible).37
- 2014-04-02 Colonoscopy: Active severe ileitis.14
- 2014-03 Colonoscopy: Active ileitis (per course narrative).14
- 2013-07 Colonoscopy: Stricture suggested in the terminal ileum; no active colonic inflammation.38
- 2012-06 Colonoscopy: Active ileal disease and patch left-sided colitis.14
- 2011-04 Colonoscopy: Quiescent colitis.14
- 2010-11 Colonoscopy: Colitis in the descending colon; rectum normal.1
- 2008 Colonoscopy: Non-specific colitis.1

Pathology:
- 2022-02-28, neoterminal ileum: Chronic inactive ileitis with pyloric metaplasia including gastric-type parietal cells; negative for dysplasia.30
- 2022-02-28, right/transverse/left colon and rectum: Mild architectural distortion suggestive of prior mucosal injury; negative for dysplasia.30
- 2015-05-13, neo ileum: Focal active ileitis; no granulomas identified.36
- 2015-05-13, rectum: Mild hyperplastic/regenerative changes, otherwise within normal limits; negative for dysplasia.36
- 2014-04-02, neo ileum: Focal acute ileitis.14
- 2014-04-02, cecum: Normal colonic mucosa; no changes of inflammatory bowel disease, no dysplasia, no malignancy.14
- 2014-01-06, ileocolectomy specimen (terminal ileum, appendix, cecum, proximal ascending colon): Severe ulcerating and stricturing Crohn's disease with multiple terminal ileum strictures; erosions/undermining ulcers at the proximal margin; appendix unremarkable; distal margin and lymph nodes unremarkable.39
- 2012-07-11, colonoscopic biopsies: Rectum patchy inactive Crohn's colitis; descending colon (30 cm) patchy active chronic colitis consistent with Crohn's; ascending colon inactive Crohn's colitis; transverse colon (55 and 70 cm) and cecum no diagnostic abnormality.40
- 2011-04-27, biopsies: Terminal ileum, right colon, left colon: no pathological diagnosis; rectum: mild chronic colitis consistent with quiescent ulcerative colitis on a second specimen.41
- 2010-11-14, biopsies: Ileum mild active chronic ileitis consistent with Crohn's; sigmoid focal active colitis with cryptitis and crypt abscesses, one granuloma possibly crypt rupture-related; descending colon focal active colitis; second descending colon specimen suggestive of hyperplastic polyp with no evidence of colitis.42

Imaging:
- 2021-03-04 CT enterography: Long segment (30-40 cm) active inflammation in the distal ileum including the neoterminal ileum, acute on chronic inflammation; thin soft tissue band near the anastomosis — a fibrosed fistulous tract cannot be excluded; small outpouching likely ulceration; extent similar to prior imaging; no drainable collections.11
- 2019-05-06 MR enterography: Recurrent neoterminal ileal disease spanning at least 20 cm with moderate mural thickening, at least one penetrating aphthous ulcer, and luminal narrowing with stricturing; impression of a fistulous communication between two diseased small bowel segments; mild active features on a background of chronic change; no obstruction, collections, or abscess.43
- 2018-04-14 CT abdomen and pelvis (renal colic protocol): No obstructing calculi; marked hepatomegaly (~25 cm); gallstones; colonic diverticula without diverticulitis; prior small bowel resection; small fat-containing left inguinal hernia.13
- 2016-05-16 CT enterography: ~10-15 cm of distal ileum including the neoterminal ileum with moderate active inflammation on a background of mild chronic granulomatous ileitis; no stricture, fistula, sinus tract, abscess, or phlegmon; mildly enlarged ileocolic mesenteric nodes; mild hepatic fatty infiltration.44
- 2013-06 MRI abdomen/pelvis: 55-60 cm segment of thickened terminal ileum; obstructive symptoms led to surgical admission.45
- 2012-04 MR enterography: Long segment of ileal inflammation; incidental Meckel's diverticulum.14
- 2011-04 Small bowel follow-through: Active ileitis with stenotic and dilated segments.14