Abdominal Pain and Diarrhea

Morning Report November 16, 2012 Hannah Kirking, Med/Peds, PGY3

17 yo previously healthy male

Six weeks of crampy abdominal pain, mostly periumbilical in location Pain is worse after eating and before bowel movements, slightly better after BMs Pain present almost everyday 5-10 lb weight loss in this period Stools have also been looser during this time, with intermittent diarrhea No blood

History of Present Illness

No fevers, rashes, emesis, urinary symptoms PCP interventions:
Prilosec and Carafate (no improvement) Metronidazole for presumed possible C-difficile (8 days prior to presentation), minimal improvement

Yesterday afternoonpain acutely worsened with very severe cramping that led to his presentation to PCMC ED

Medical History
Past Medical History Medications/Allergies/Imms

Seasonal allergies Appendectomy in 2008 No previous GI conditions or symptoms

Medications: Zyrtec PRN No known drug allergies

Family/Social history
No Family History of:
IBD Ankylosing spondylitis Arthritis Psoriasis

Dad has GERD

Lives with parents and younger brother. Patient is in 12th grade and plays the guitar. He is looking into colleges with good music programs after high school. He denies alcohol, tobacco or illicit drug use other than using marijuana once.

Physical Exam: Vitals

VS: T 39.6. HR 119. RR 24. BP 101/53. SaO2 98% on Room Air. Wt: 57.1 Kg (15%tile), Ht: 178 cm (61%tile)

Physical Exam
GENERAL: Awake, alert, pleasant, in NAD

HEENT: normocephalic, atraumatic, PERRL, EOMI, conjugate gaze, normal conjunctivae, TM clear bilaterally, oropharynx clear without tonsillar exudates
NECK: supple, no LAD or thyromegaly CV: tachycardic, normal rhythm, no murmur, normal pulses LUNGS: CTAB, normal effort ABDOMEN: soft, moderate tenderness in lower quadrants bilaterally, no rebound, no masses, normal bowel sounds EXT: all extremities warm and well perfused, no cyanosis, clubbing, or edema. GU: normal male external genitalia, tanner stage 4, no anal lesions NEUROLOGIC: awake and alert, cranial nerves II-XII grossly intact, grossly normal strength

SKIN: no rashes

Differential Diagnosis
Infectious
Shigella Salmonella Campylobacter E coli Yersinia C difficile Viral Cryptosporidiosis Amoeba

Vascular
AVM (HHT/Osler-Weber-Rendu syndrome) Solitary Rectal Ulcer Syndrome Rectal fissure

Heme/Onc
Juvenile polyps GIST Typhlitis Lymphoma

Autoimmune
Late-onset food allergy Crohns disease Ulcerative colitis

Labs
CBC: WBC 10.2 (69N, 6B, 16L, 6M, 2E, 1B), Hb 16.3, Hct 47.8, Plt 201 CMP: Na 135, K 4.3, Cl 100, bicarb 26, BUN 12, Cr 0.77, gluc 85, Ca 9.2, prot 7.1, alb 3.9, t bili 0.5, alk phos 69, AST 27, ALT 37 GGT 23 CRP 1.7, ESR 5, lipase 85 EHEC negative, C diff negative

Hospital Day 1

Coronoal CT Images

Axonal CT Images

CT Abd/Pelvis
The extensive thickening of the distal ileum to the level of the ileocecal valve and the affiliated fat stranding is most consistent with inflammatory bowel disease such as Crohn's disease. Numerous small lymph nodes are noted. Infectious causes of small bowel inflammatory thickening are also within the differential diagnosis. Free pelvic fluid is identified. Intestinal lymphoma would be a very unlikely explanation for the imaging findings.

EGD Report
Terminal ileitis with 2 tiny discrete lesions in proximal sigmoid colon, otherwise normal upper and lower endoscopy. Most suggestive of Crohn disease.

Hospital Day 2
Patient was having small stools

Treatment
Solumedrol 30 mg IV Qday 30 mg IV BID

Clinical Course
One day after increase in steroids Two days after increase in steroids

Patient improved one day after increasing steroids and TPNwas playing guitar, abdominal pain better, etc. WBC count increased, presumably from steroids.

Patients abdominal exam worsened, WBC continued to climb along with CRP, and following xray was obtained

Hospital Day 6
Impression: Obstructive small bowel pattern, significantly progressed since the previous study 4 days ago. Findings indicate a high-grade distal small bowel obstruction.

Surgical diagnosis
Findings Surgical Pathology

Crohn's disease with isolated ileocecal inflammatory process with occult perforation and feculant peritonitis.

Terminal ileum and proximal colon, segmental resection: chronic active granulomatous enterocolitis with fistula and acute peritonitis with foreign body reaction, consistent with Crohns disease.

IBD in Kids
Diarrhea (with or without blood) is most common presenting symptom
80 percent of patients with Crohns disease 100 percent of patients with ulcerative colitis

Weight loss or growth failure (especially in those with Crohn disease) Iron deficiency Elevated inflammatory markers Some patients with IBD may have extraintestinal symptoms anorexia, arthralgia, erythema nodosum, fevers

IBD Treatment
Crohns Ulcerative Colitis

Steroids 6MP or Azathioprine Methotrexate Infliximab (Remicade) Surgery Consider adalimumab, thalidomide, natalizumab, cyclosporine

Steroids (often suppositories/enemas) 5-ASA medications (start with suppositories/enemas) Systemic treatment with sulfasalazine, mesalamine, balsalazide Surgery depending on symptoms/patient preference