crohns additional info Flashcards
A 21-year-old Caucasian woman is referred to the gastroenterology clinic from her GP with a one year history of right iliac fossa pain and a palpable mass.
The pain is described as colicky in nature with varying frequency and intensity. She opens her bowels 3 times a day which is runny in consistency with no mucus or blood. Prior to a year ago her bowel habit was once every 2 days. She gets some bloating along with the pain but no nausea or vomiting. She complains of extreme fatigue and has noted about one stone of weight loss in the last year.
She has no history of foreign travel or past medical history.
She has no allergies and currently takes paracetamol when required for pain relief.
She has smoked 15 cigarettes a day since the age of 14 and drinks alcohol very occasionally on a social basis.
On examination, she appears well and is afebrile. Abdominal examination reveals a tender palpable mass, approximately 10 cm in size, present in the right iliac fossa. There is no organomegaly.
What is the most likely diagnosis?
crohns disease
The patient’s age, the nature and chronicity of symptoms, the presence of the mass and the demographic data make Crohn’s disease by far the most likely diagnosis.
Right iliac fossa mass differential diagnosis
The differential diagnosis for a right iliac fossa (RIF) mass includes:
Crohn’s disease
Appendix mass or abscess
Caecal carcinoma,
Ovarian or renal mass,
TB, Actinomycosis or amoebic abscess
2 beneficial tests in conforming crohns disease
- cross sectional imaging with CT or MRI
- Colonoscopy
Cross-sectional imaging is important in the presence of the mass and this should probably be done first in order to make sure there is no contraindication to invasive investigations. In young people, particularly with IBD where they are likely to require multiple investigations over the course of their life MRI is preferred but if there is urgent concern about possible perforation etc. then CT would be acceptable.
Colonoscopy will be very likely to yield the diagnosis and allow confirmation with histological samples.
A colonoscopy was performed that showed patchy pan-colonic inflammation, with ulceration at the ileal-caecal junction. Histology confirmed active Crohn’s disease. By this stage the patient reports that she is in constant pain and struggling to eat well. She has lost a further half a stone whilst she was waiting for the results to come through. She still appears well, with stable observations and no change in her abdominal examination. Which 2 treatments would be the most effective in improving her symptoms at this point?
- systemic steroids eg. prednisolone 40mg once per day
- exclusive enteral nutrition
The patient is sick and needs a treatment that will act quickly and effectively. The 2 options that will achieve this are steroids and exclusive enteral nutrition.
drug for maintenance of remission in crohns
Azathioprine takes 3 months to work and so will not help in the acute situation. Introducing a thiopurine at this point may be correct, but only as a long-term plan for maintenance of remission – not as an induction agent.
