A 32-year-old woman comes to the office due to intermittent abdominal pain and nonbloody diarrhea for the past 3-4 months. She describes the pain as crampy and located in the mid-abdomen and right lower quadrant. The patient thinks she has lost some weight during this period. She modified her diet several times in an attempt to decrease the symptoms, believing that heavy meals exacerbate the pain and diarrhea. The patient underwent appendectomy with abscess debridement one year ago. She has no other medical issues and takes no medication other than oral contraceptives. She has not traveled outside the United States and does not use tobacco, alcohol, or recreational drugs. Temperature is 36.7 C (98 F), blood pressure is 120/70 mm Hg, pulse is 85/min, and respirations are 14/min. A few shallow ulcers are present in her mouth. Abdominal examination shows mild tenderness in the right lower quadrant without rebound. Laboratory results are as follows:
Hemoglobin 10.2 g/dL Leukocytes 14,500/mm3 Platelets 530,000/mm3 Erythrocyte sedimentation rate 48 mm/hr
Which of the following is the most likely diagnosis for this patient?
Crohn disease | |
Clinical findings |
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Diagnosis |
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Treatment |
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TNF = tumor necrosis factor. | |
This patient with chronic abdominal pain, diarrhea, weight loss, and evidence of inflammation (elevated erythrocyte sedimentation rate [ESR]) likely has Crohn disease. Other frequent gastrointestinal manifestations of Crohn disease include microscopic bleeding, fistula and stricture formation, abdominal abscesses, and malabsorption. It can involve any part of the gastrointestinal tract from mouth (eg, aphthous ulcers) to anus. Common extraintestinal symptoms include arthritis, uveitis, scleritis, and erythema nodosum. Laboratory findings are similar to other chronic inflammatory diseases and can include leukocytosis, anemia, reactive thrombocytosis, and elevated inflammatory markers (eg, ESR). Diagnosis is confirmed with endoscopic or radiographic studies, and treatment involves immunosuppressive therapy.
(Choice A) Although celiac disease can also present with chronic diarrhea, abdominal pain, weight loss, and anemia from malabsorption, elevated inflammatory markers are uncommon, as are oral manifestations.
(Choice C) Chronic giardiasis commonly presents with loose, greasy stools, significant weight loss, and abdominal cramping; however, oral involvement, anemia, and elevated inflammatory markers are not typical. Moreover, this patient does not have clear risk factors for Giardia infection (eg, international travel, hiking).
(Choices D and E) Irritable bowel syndrome and lactose intolerance are not commonly associated with weight loss, anemia, leukocytosis, or elevated inflammatory markers. Such findings should prompt evaluation for other causes of gastrointestinal complaints.
(Choice F) Ulcerative colitis more frequently presents as bloody (rather than nonbloody) diarrhea with tenesmus and incontinence, and does not involve the oral mucosa.
(Choice G) Infectious colitis due to a number of bacteria (including Yersinia), parasites, or amoebae can closely mimic Crohn disease, especially if it presents with ileitis. However, infectious colitis is a more acute process and does not involve the oral mucosa.
Educational objective:
Crohn disease is characterized by chronic abdominal pain, diarrhea, weight loss, and evidence of inflammation (eg, anemia, elevated inflammatory markers). It can involve any part of the gastrointestinal tract from mouth to anus.