HPI
• A 25 year old Caucasian male presents to your
clinic with two month history of crampy
abdominal pain and diarrhea.
• What else would you like to know?
HPI continued
• Patient also complains of feeling fatigued with an
overall lack of energy for the past two months.
• He reports a ten pound weight loss since the
diarrhea started two months ago.
• He has occasionally experienced low grade fevers
during this time period.
• Patient also reports some achiness in his right
shoulder joint and his left knee. This feeling seems to
come and go.
• Patient denied gross blood seen in stool.
Medical History
• Past medical history: Exercise-induced asthma
• Past surgical history: Tonsillectomy
• Family History: Maternal grandmother with “sensitive stomach”
• Social History: Smokes half a pack per day, drinks alcohol socially,
denies other illicits. Works as a water aerobics instructor.
• Medications: Albuterol inhaler prior to exercise
• Allergies: Penicillin
Patient recap
25 year old male with a two month history of:
-diarrhea
-crampy abdominal pain
-ten pound weight loss
-occasional low-grade fever
-migratory arthralgias
What is on our differential diagnosis??
Differential diagnosis
• Irritable bowel syndrome
• Lactose intolerance
• Inflammatory bowel disease
– Crohn’s disease
– Ulcerative colitis
• Celiac disease
• Infectious colitis
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–
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Bacterial (ie salmonella)
Viral (ie HIV)
Fungal (ie histoplasmosis)
Parasitic (ie amebiasis)
• Neoplastic
– Lymphoma
– Carcinoid
– Etc.
What should we do next??
Focused Physical Exam
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Vital signs: Temp 98.6 F, BP 122/78, HR 80, RR 18
General: Alert male with slim build. No acute distress.
Skin: Pale skin without evidence of rashes.
Abdominal exam:
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Scaphoid abdomen.
Soft with diffuse tenderness upon palpation.
Hyperactive bowel sounds appreciated.
No organomegaly noted.
• Rectal exam: Appropriate sphincter tone. No fissures or
abscesses noted. Fecal occult blood test positive.
• What tests should we order??
Tests
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WBC 12.5 (elevated)
Hgb 12.0 (low)
ESR 25 mm/hr (elevated)
CRP 14 mg/L (elevated)
BMP normal
Stool tests for ova and parasites negative
Would you like any imaging?
Colonoscopy Results
•Colonoscopy showed areas of inflammation that seemed to
skip throughout normal mucosa of the terminal ileum and
colon.
•Cobblestoning mucosa was also seen, with deep “linear
cracks” dispersed throughout the mucosa.
•Biopsies were taken and results are seen on the next slide..
Biopsy
A biopsy from one
of the “skip
lesions” shows an
infiltration of
inflammatory cells
interspersed with
epilthelioid
granulomas, as
well as atrophy of
the crypts.
Resolution
• Gastroenterology referral was ordered for
treatment of inflammation bowel disease.
• The final pathology was consistent with
Crohn’s disease.
Epidemiology of Crohn’s Disease (CD)
• CD is a type of inflammatory bowel disease with a
bimodal age of onset. It usually strikes between 15-30
years old, and then between 60-80 years old.
• Smoking doubles a person’s risk of developing CD. (Our
patient here is a smoker, right?)
• It is estimated that around five to ten percent of
patients with Crohn’s Disease have a family history of
the disease. The remaining majority of patients have
no family history.
Clinical Presentation
• The most common symptoms of CD are abdominal pain and
diarrhea.
• Fever, weight loss, and fatigue are other common
symptoms.
• Extraintestinal manifestations can include:
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Arthritis (most commonly)
Eye problems (ie uveitis, iritis)
Skin problems (ie erythema nodosum, pyoderma gangrenosum)
Renal stones
Osteoporosis
Vitamin B12 deficiency
Histological Characteristics
• Macroscopically, CD is characterized by transmural
inflammation that can occur anywhere along the GI tract
from the mouth to the anus.
• From 75-80% of patient have disease involvement in the small
intestine- most commonly the terminal ileum.
In the picture to the
right we see thickened,
stenotic colon wall.
There are interspersed
areas of ulcerations and
the cobblestoned
appearance is
characteristic of CD.
Here is a slide displaying a characteristic transmural ulcer in the
colon, in which a fissure can now be seen. The fissure is lined by
many different cells, including epithelioid histiocytes and giant
cells.
Above we can see a crypt abscess, which can occur in active CD.
The abscess if composed of inflammatory neutrophils. These
abscesses often have to be drained under CT guidance if
unresponsive to medicine.
Additional imaging
• Obtaining a CT
scan can be
helpful to
determine the
extent disease.
•The CT above displays:
-Thickening of the terminal ileum wall
-Inflammation in the surrounding mesentery
•Other possible CT findings with Crohn’s disease include:
-Abscesses
-Fistulas
-Strictures
Treatment
•
Treatment can vary depending on the extent of disease and the symptoms
experience by the patient. Below is a list of the range of options available to patients
with CD. More in depth discussion of treatment options will occur in third year
rotations.
•
Oral 5-aminosalicylates
– i.e. sulfasalazine
•
Antibiotics
– ciprofloxacin, metronidazole
•
Steroids
– i.e. prednisone
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Immunomodulators
– i.e. azathioprine, methotrexate
•
Biologics
– i.e. infliximab, adalimumab