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 ETIOLOGY Pathogenesis mechanism chronic Th1-mediated inflammation starts as focal inflammatory infiltrates around crypts, evolves into transmural inflammation and noncaseating granulomas 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 Prognosis Unpredictable course of relapses and remissions
QUESTIONS 1 of 10 1 2 3 4 5 6 7 8 9 10 Previous Next Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK (M2.GI.15.4672) 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? QID: 107179 Type & Select Correct Answer 1 Diffuse, non-focal ulcerations with granuloma 29% (28/98) 2 Diffuse, non-focal ulcerations without granuloma 17% (17/98) 3 Pseudopolyps and continuous mucosal involvement 18% (18/98) 4 Focal ulcerations with granuloma 28% (27/98) 5 Friable mucosa with pinpoint hemorrhages 6% (6/98) M 6 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M2.GI.15.4672) 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? QID: 107181 FIGURES: A Type & Select Correct Answer 1 Long-term poorly managed diabetes mellitus 4% (1/25) 2 New onset of multiple sclerosis 16% (4/25) 3 Manifestation of a previously untreated syphilis infection 0% (0/25) 4 Consequence of ileal resection 68% (17/25) 5 Autoimmune destruction of gastric parietal cells 8% (2/25) M 6 Question Complexity C Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 4 Review Tested Concept Review Full Topic (M2.GI.14.5) 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/LCl-: 100 mEq/LK+: 3.3 mEq/LHCO3-: 25 mEq/LBUN: 20 mg/dLGlucose: 90 mg/dLCreatinine: 1.4 mg/dLCa2+: 10.2 mg/dLWhich of the following is the most appropriate initial step in management? QID: 105615 FIGURES: A Type & Select Correct Answer 1 Abdominal ultrasound 17% (1/6) 2 Budesonide 0% (0/6) 3 CT abdomen 33% (2/6) 4 Mesalamine 33% (2/6) 5 Ringer lactate 17% (1/6) M 7 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 Review Tested Concept Review Full Topic
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