33 Year Old Man With Watery Diarrhea, Abdominal Pain And Weight Loss

A 33 year old man presents to the clinic with the complains of watery diarrhea, diffuse abdominal pain and gradual weight loss over the past 3 weeks. He has been given antibiotics but his diarrhea is not responding. He mentions having a similar problem 6 months back. His appetite has decreased and he describes having painful ulcers in his mouth that makes eating difficult and painful.
On examination he looks pale and in mild discomfort. He has a fever of 101 F.  His abdomen in mildly tender on palpation but there is no visceromegaly.
Based on the above history and examination what is the differential diagnosis?

Differential Diagnosis:

• Gastroenteritis.
• Inflammatory bowel disease
• Pseudomembranous colitis
• Small bowel lymphoma
• HIV induced Infection
• Carcinoid

What Lab test and workup will you advice for this patient?

Workup:

• Complete blood count
• Serum electrolytes
• Stool exam and culture
• Colonoscopy
• CT abdomen
• Urinary 5- HIAA
• Small bowel series.

This patient was scheduled for a colonoscopy and the following was observed:

Colonoscopic image showing erythematous and friable mucosa with numerous pseudopolyps .

The colonoscopic findings were suggestive of Crohn's disease.

Case discussion :

Crohn's Disease:

It is an inflammatory bowel disease but different from ulcerative colitis. Crohn's disease most commonly affects the end of the small bowel (the ileum) and the beginning of the colon but it can affect any part of the GI tract from the mouth upto the anus. 

Clinical features:

The usual age of onset is between 15 to 30 years of age, but it can occur at any age. Patients with crohn's disease experience chronic recurring periods of flare ups and remission. 

GI Symptoms:

• Abdominal pain
• Diarrhea
• The nature of diarrhea depends upon the portion of intestine involved.
• Bloating
• Flatulence
• Perianal discomfort with itching, pain or skin tags.
• non- healing oral ulcers

Systemic Manifestation:

• Growth failure among children
• fever
• Weight loss
• Loss of appetite

Extraintestinal Symptoms:

• Uveitis (inflammation of interior portion of eye)
• Episceritis (inflammation involving the white part of the eye)
• increased risk of gallstones
• seronegative spondyloarthropathy with joint pain
• erythema nodosum (raised tender red nodules most commonly on the shin)
• pyoderma gangrenosum (a painful ulcerating skin nodule)
• Anemia
• Osteoporosis
• Clubbing

Pathology:

Characteristic endoscopic findings include skip lesions, cobblestoning, ulcerations and strictures. Histology may show neutrophillic inflammation, non caseating granulomas, Paneth cell metaplasia and intestinal villi blunting. 

Management:

Acute treatment includes medicines to treat any infections (i. e antibiotics) and to reduce inflammation ( aminosalicylate antiinflammatory and corticosteroid drugs) 

When in remission the goal of treatment is to prevent recurrence of symptoms.