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Snapshot
  • A 16-year-old girl presents to her gastroenterologist with severe, crampy, abdominal pain and intermittent nonbloody diarrhea. She has also had unexpected weight loss over the past few months. She also reports having irritating sores in her mouth. On exam, she is noted to have aphthous sores on the bucca mucosal, and skin tags around the anus. A colonoscopy a week later shows cobblestone mucosa and non-contiguous involvement of the small intestine, suggesting a diagnosis of Crohn disease.
Introduction
  • Overview
    • Crohn disease is an inflammatory bowel disease that can affect any part of the gastrointestinal (GI) tract, including the mouth and the anus  
      • characterized by abdominal pain and nonbloody diarrhea
      • classically associated with non-contiguous involvement, or “skip lesions”, along GI tract
  • Epidemiology
    • demographics
      • onset 15-30 or 60-70s years of age
    • risk factors
      • family history
  • Pathogenesis
    • mechanism
      • chronic Th1-mediated inflammation
        • starts as focal inflammatory infiltrates around crypts, evolves into transmural inflammation and noncaseating granulomas
  • Prognosis
    • unpredictable course of relapses and remissions
Presentation
  • Symptoms
    • GI symptoms
      • results from transmural involvement
      • abdominal pain
      • bloody or nonbloody diarrhea
      • abscess
      • fistulas 
      • strictures
      • malnutrition
    • extraintestinal manifestations
      • arthralgias
      • kidney stones
        • calcium oxalate
      • ankylosing spondylitis
    • systemic symptoms
      • chronic intermittent fever
      • weight loss
      • fatigue
  • Physical exam
    • skin and mucosal findings
      • pyoderma gangrenosum
      • erythema nodosum
      • aphthous stomatitis
      • perianal region
        • skin tags
        • scarring
    • ocular finding
      • episcleritis
      • uveitis
Imaging
  • Abdominal radiograph
    • indications
      • assess for bowel obstruction
  • CT of abdomen
    • indications
      • evaluation for obstruction, fistulas, or abscesses
Studies
  • Serum labs
    • serology used when endoscopic studies and barium studies are inconclusive
      • anti-Saccharomyces cerevisiae positive
      • anti-neutrophil cytoplasmic antibody negative
    • complete blood cell count
    • elevated inflammatory markers
  • Invasive studies
    • colonoscopy or esophagogastroduodenoscopy
      • indication
        • diagnostic
      • findings
        • cobblestone mucosa
        • transmural inflammation
        • skip lesions
        • bowel wall thickening
        • ulcers
        • fissures
  • Histology
    • noncaseating granulomas
    • lymphoid aggregates
Differential
  • Ulcerative colitis
    • key distinguishing factors
      • bloody diarrhea
      • disease affecting colon and always the rectum
      • mucosal and submucosal inflammation only
Treatment
  • Medical
    • 5-aminosalicylic acid agents
      • indications
        • mild disease
        • initial therapy
      • drugs
        • mesalamine
          • best initial therapy
        • sulfasalazine
    • corticosteroids
      • indications
        • for flares
    • immunosuppressive agents
      • drugs
        • infliximab
          • good for those with fistula formation
        • azathioprine
          • recurrent symptoms off steroids
    • antibiotics
      • drugs
        • metronidazole/ciprofloxacin
          • perianal involvement
    • anti-diarrheal medications
      • drugs
        • loperamide
    • replace fat soluble vitamins
      • vitamin D 
        • can lead to hypocalcemia, hypophosphatemia, and secondary hyperparathyroidism
  • Surgical
    • surgical resection of affected area
      • indications
        • not curative
Complications
  • Fistula formation
  • Colorectal cancer
  • Abscesses
  • Strictures
 

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Questions (8)
Lab Values
Blood, Plasma, Serum Reference Range
ALT 8-20 U/L
Amylase, serum 25-125 U/L
AST 8-20 U/L
Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL
Calcium, serum (Ca2+) 8.4-10.2 mg/dL
Cholesterol, serum Rec: < 200 mg/dL
Cortisol, serum 0800 h: 5-23 μg/dL //1600 h:
3-15 μg/dL
2000 h: ≤ 50% of 0800 h
Creatine kinase, serum Male: 25-90 U/L
Female: 10-70 U/L
Creatinine, serum 0.6-1.2 mg/dL
Electrolytes, serum  
Sodium (Na+) 136-145 mEq/L
Chloride (Cl-) 95-105 mEq/L
Potassium (K+) 3.5-5.0 mEq/L
Bicarbonate (HCO3-) 22-28 mEq/L
Magnesium (Mg2+) 1.5-2.0 mEq/L
Estriol, total, serum (in pregnancy)  
24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL
28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL
Ferritin, serum Male: 15-200 ng/mL
Female: 12-150 ng/mL
Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL
Female: premenopause: 4-30 mIU/mL
midcycle peak: 10-90 mIU/mL
postmenopause: 40-250
pH 7.35-7.45
PCO2 33-45 mmHg
PO2 75-105 mmHg
Glucose, serum Fasting: 70-110 mg/dL
2-h postprandial:<120 mg/dL
Growth hormone - arginine stimulation Fasting: <5 ng/mL
Provocative stimuli: > 7ng/mL
Immunoglobulins, serum  
IgA 76-390 mg/dL
IgE 0-380 IU/mL
IgG 650-1500 mg/dL
IgM 40-345 mg/dL
Iron 50-170 μg/dL
Lactate dehydrogenase, serum 45-90 U/L
Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL
Female: follicular phase: 5-30 mIU/mL
midcycle: 75-150 mIU/mL
postmenopause 30-200 mIU/mL
Osmolality, serum 275-295 mOsmol/kd H2O
Parathyroid hormone, serume, N-terminal 230-630 pg/mL
Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L
Phosphorus (inorganic), serum 3.0-4.5 mg/dL
Prolactin, serum (hPRL) < 20 ng/mL
Proteins, serum  
Total (recumbent) 6.0-7.8 g/dL
Albumin 3.5-5.5 g/dL
Globulin 2.3-3.5 g/dL
Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL
Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h
Thyroxine (T4), serum 5-12 μg/dL
Triglycerides, serum 35-160 mg/dL
Triiodothyronine (T3), serum (RIA) 115-190 ng/dL
Triiodothyronine (T3) resin uptake 25%-35%
Urea nitrogen, serum 7-18 mg/dL
Uric acid, serum 3.0-8.2 mg/dL
Hematologic Reference Range
Bleeding time 2-7 minutes
Erythrocyte count Male: 4.3-5.9 million/mm3
Female: 3.5-5.5 million mm3
Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/h
Female: 0-20 mm/h
Hematocrit Male: 41%-53%
Female: 36%-46%
Hemoglobin A1c ≤ 6 %
Hemoglobin, blood Male: 13.5-17.5 g/dL
Female: 12.0-16.0 g/dL
Hemoglobin, plasma 1-4 mg/dL
Leukocyte count and differential  
Leukocyte count 4,500-11,000/mm3
Segmented neutrophils 54%-62%
Bands 3%-5%
Eosinophils 1%-3%
Basophils 0%-0.75%
Lymphocytes 25%-33%
Monocytes 3%-7%
Mean corpuscular hemoglobin 25.4-34.6 pg/cell
Mean corpuscular hemoglobin concentration 31%-36% Hb/cell
Mean corpuscular volume 80-100 μm3
Partial thromboplastin time (activated) 25-40 seconds
Platelet count 150,000-400,000/mm3
Prothrombin time 11-15 seconds
Reticulocyte count 0.5%-1.5% of red cells
Thrombin time < 2 seconds deviation from control
Volume  
Plasma Male: 25-43 mL/kg
Female: 28-45 mL/kg
Red cell Male: 20-36 mL/kg
Female: 19-31 mL/kg
Cerebrospinal Fluid Reference Range
Cell count 0-5/mm3
Chloride 118-132 mEq/L
Gamma globulin 3%-12% total proteins
Glucose 40-70 mg/dL
Pressure 70-180 mm H2O
Proteins, total < 40 mg/dL
Sweat Reference Range
Chloride 0-35 mmol/L
Urine  
Calcium 100-300 mg/24 h
Chloride Varies with intake
Creatinine clearance Male: 97-137 mL/min
Female: 88-128 mL/min
Estriol, total (in pregnancy)  
30 wks 6-18 mg/24 h
35 wks 9-28 mg/24 h
40 wks 13-42 mg/24 h
17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 h
Female: 2.0-8.0 mg/24 h
17-Ketosteroids, total Male: 8-20 mg/24 h
Female: 6-15 mg/24 h
Osmolality 50-1400 mOsmol/kg H2O
Oxalate 8-40 μg/mL
Potassium Varies with diet
Proteins, total < 150 mg/24 h
Sodium Varies with diet
Uric acid Varies with diet
Body Mass Index (BMI) Adult: 19-25 kg/m2
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(M2.GI.5) A 27-year-old man presents to the emergency department for weakness and fatigue. His symptoms started 3 days ago and have been gradually worsening. The patient has a history of poorly managed Crohn disease and currently has a complication being managed by his surgeon. This past month, he has had 4 episodes of severe abdominal pain requiring admission. His temperature is 97.6°F (36.4°C), blood pressure is 114/64 mmHg, pulse is 120/min, respirations are 12/min, and oxygen saturation is 98% on room air. Physical exam is notable for the finding in Figure A which is suctioned and cleaned. His abdomen is nontender. Laboratory studies are ordered as seen below.

Serum:
Na+: 139 mEq/L
Cl-: 100 mEq/L
K+: 3.3 mEq/L
HCO3-: 25 mEq/L
BUN: 20 mg/dL
Glucose: 90 mg/dL
Creatinine: 1.4 mg/dL
Ca2+: 10.2 mg/dL

Which of the following is the most appropriate initial step in management?
Review Topic

QID: 105615
FIGURES:
1

Abdominal ultrasound

0%

(0/0)

2

Budesonide

0%

(0/0)

3

CT abdomen

0%

(0/0)

4

Mesalamine

0%

(0/0)

5

Ringer lactate

0%

(0/0)

M2

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(M2.GI.4672) A 25-year-old woman presents to her primary care physician complaining of several months of diarrhea. She has also had crampy abdominal pain. She has tried modifying her diet without improvement. She has many watery, non-bloody bowel movements per day. She also reports feeling fatigued. The patient has not recently traveled outside of the country. She has lost 10 pounds since her visit last year, and her BMI is now 20. On exam, she has skin tags and an anal fissure. Which of the following would most likely be seen on endoscopy and biopsy? Review Topic

QID: 107179
1

Diffuse, non-focal ulcerations with granuloma

30%

(22/73)

2

Diffuse, non-focal ulcerations without granuloma

18%

(13/73)

3

Pseudopolyps and continuous mucosal involvement

15%

(11/73)

4

Focal ulcerations with granuloma

27%

(20/73)

5

Friable mucosa with pinpoint hemorrhages

8%

(6/73)

M2

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(M2.GI.4672) A 42-year-old female presents to her primary care provider complaining of numbness and tingling bilaterally in her hands for the past month. She has a past medical history of Crohn’s disease and underwent ileal resection 2 years ago. Previously, laboratory studies demonstrated glucose intolerance, which has been managed with lifestyle modifications. The patient’s vital signs are T 98.7 F, HR 98, BP 128/76, and O2 Sat 98%. CBC demonstrates a WBC 7.0, Hgb 10.8, Hct 31.1, and MCV 110. The patient’s Hgb A1c is 5.6%. MRI spine is performed, which shows the following finding (Figure A). What is the most likely cause of the patient’s presentation? Review Topic

QID: 107181
FIGURES:
1

Long-term poorly managed diabetes mellitus

5%

(1/20)

2

New onset of multiple sclerosis

15%

(3/20)

3

Manifestation of a previously untreated syphilis infection

0%

(0/20)

4

Consequence of ileal resection

70%

(14/20)

5

Autoimmune destruction of gastric parietal cells

5%

(1/20)

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