Review Question - QID 105615

This patient is presenting with an enterocutaneous fistula given his physical exam finding and history of Crohn disease. Given his tachycardia, he is likely dehydrated and needs IV fluids from this enterocutaneous fistula.

Crohn disease is an inflammatory condition that presents with GI symptoms from mouth to anus including perirectal findings (such as abscesses or fistulas), GI bleeding (usually not grossly bloody but detected by fecal occult testing), small bowel findings (such as B12 deficiency from terminal ileum involvement), and oral ulcers. Other systemic findings can include fevers, malaise, erythema nodosum, and pyoderma gangrenosum. Crohn disease can cause transmural inflammation of the bowel which can potentially cause an enterocutaneous fistula which is a connection between the bowel and the skin. The management of an enterocutaneous fistula is to first replete fluids and electrolytes as there tends to be dehydration and derangements in these patients. The treatment can involve supportive therapy which may lead to resolution. However, if symptoms persist, surgical correction may be needed.

Incorrect Answers:
Answer 1: Abdominal ultrasound would be indicated in the workup of cholecystitis which presents in an overweight woman with right upper quadrant abdominal pain that is typically worsened by fatty meals and alcohol. It could also be used to work up appendicitis in pediatric patients and pregnant women to avoid radiation exposure.

Answer 2: Budesonide is a steroid with first pass metabolism in the liver making it ideal for Crohn disease as it has minimal systemic effects when compared to other steroids. This patient does not seem to be having an acute Crohn flare and his vitals are unstable making fluids a better answer choice.

Answer 3: CT abdomen may be indicated if the patient had tenderness or a fever as this would be concerning for an abscess; however, this patient's enterocutaneous fistula appears unremarkable and supportive care for the fistula is all that is needed for now. Prior to further more aggressive workup, this patient should be given fluids given his tachycardia.

Answer 4: Mesalamine is an appropriate initial treatment for Crohn disease as it reduces inflammation in the colon. This medication would be indicated for a Crohn flare but would not be the most appropriate initial step in management.

Bullet Summary:
Enterocutaneous fistula is a potential complication of Crohn disease and fluid and electrolyte replacement is the most appropriate initial step in management.