Discussion 2,3,4,5,6,7,8,9,10

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An 18-year-old white female presents to your clinic today with a 2-week history of intermittent
abdominal pain.She also is positive for periodic cramping and diarrhea as well as low grade fever.
She also notes reduced appetite. She notes that She admits smoking ½ PPD for the last 2 years.
Denies any illegal drug or alcohol use. Does note a positive history of Crohn’s Disease.Based on the
information provided answer the following questions:
1. What are the top 3 differentials you would consider with the presumptive final diagnosis
listed first?
According to Epocrates.com (2020), the top three differential diagnoses would be Crohn’s disease
which Regueiro & Hashash (2019) describe as an inflammatory disease of the entire gastrointestinal
tract that can affect the walls of the digestive tract transmurally (which means throughout the wall of
the intestinal tract). Symptoms would include weight loss, anorexia, fatigue, right sided abdominal
pain that could mimic appendicitis, fever, hematochezia and perianal ulcers (Epocrates.com, 2020).
They further stated that the patient’s symptoms would dictate the severity of the flare.This patient
is positive for pain, cramping, diarrhea and low-grade fever which places her in the moderate flare
category.
Another differential would be ulcerative colitis, which is an inflammation of the mucosal wall section
of the colon usually manifesting on the left side of the abdomen and presenting with bloody diarrhea
(Epocrates.com, 2020). The patient did c/o abdominal pain but did not state where the pain was
located. The patient denied bloody diarrhea.
The last differential would be infectious colitis which is characterized by three or more loose stools
for less than 14 days and is usually associated with travel abroad or travel to areas that have endemic
cases of rotavirus, norovirus, astrovirus, or bacterial causes such as shigella, salmonella, E. coli or
other bacterial causes. The diagnosis of infectious colitis is usually done by stool testing and
treatment of the infection is by fluid and electrolyte replacement and/or treatment of the infectious
agent if the agent is bacterial or parasitic (Epocrates.com, 2020).
2. What focused physical exam findings would be beneficial to know?
According to Peppercorn & Kane (2019), when assessing the patient for crohns, the practitioner
should assess the mouth for ulcers, the abdomen for distention, masses (especially in the lower
quadrants) which could be appreciated as loops of full bowel and fistulas, sinus tracts or skin tags to
the anus which could be indicative of ulcerative processes in the rectum. Auscultation of the
abdomen would reveal hyperactive bowel sounds. History of intermittent weight loss, abdominal
pain and hematochezia are usually the diagnostic findings when diagnosing crohns disease (Buttaro
et al., 2017).
3. What diagnostic testing needs completed if any to confirm diagnosis?
Buttaro et al. (2017) states that a CBC can determine if anemia is present and also if the patient’s
platelets are elevated which could determine if active inflammation is present. CRP and ESR are
helpful in determining inflammatory bowel disease but are not specific to either colitis or crohns
disease. Buttaro et al. (2017) further stated that anemia and iron deficiency was usually indicative of
extraintestinal inflammation (such as crohns disease) and that ferritin and reticulocyte in addition to
liver labs should be monitored during flares. Genetic biomarkers such as ANCAs, perinuclear
antineutrophil cytoplasmic antibodies (pANCAs) and ASCA immunoglobulin A (IgA) and IgG; outer
membrane protein C (anti-OmpC) are helpful in diagnosing more aggressive forms of crohns disease
in patients over 18 and can be used to determine the patient’s prognosis in the future. Stool samples
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are evaluated for other forms of inflammatory processes including infection and parasitism.
Radiographic studies such as enterographic CT scans and MRI are used to determine if strictures,
inflammation, perforation or obstructions are present, especially in the small intestines. Colonoscopy
and endoscopy can be diagnostic in distinguishing UC versus crohns in that UC will have
inflammation in the bowel that is continuous with the rectal inflammation. Crohns will have more
scattered areas of transmural inflammation that has what is known as “skip lesions” or areas that are
not inflamed.
4. Using evidence-based treatment guidelines note a treatment plan.
For this patient who has moderately active crohns flares, the number one therapy would be smoking
cessation as it is not well-known what causes crohns disease in the first place (Buttaro et al., 2017)
but according to IBDClinic.ca (2020) new diagnosis of crohns disease patients revealed that about
half of these patients used tobacco products. Further, IBDClinic.ca (2020) stated that smoking
changed the bowel’s immune properties and thus set up the patient for inflammatory flares.
Regueiro & Hashash (2019) stated that the goal of treatment for crohns flares is the endoscopic,
colonoscopic and clinical remission of the disease with mucosal healing and recommended that
enteric coated budesonide (a glucocoticoid) be the first line treatment in the treatment of crohns
flares. Further, a 5-Aminosalicylates (5-ASA) such as mesalamine, pentasa or asacol achieved
remission 93% vs placebo. To prevent remission budesonide is not recommended as long-term use of
glucocorticoids can affect the patient’s immune system and complicate metabolic systems in the
patient, rather a maintenance dose of the 5-ASA that helped with remission should be continued and
the patient is to receive an ileocolonoscopy in 6-12 months to assure that remission has been
maintained. For patients that cannot maintain remission without a glucocorticoid an
immunomodulator drug such as methotrexate or azathioprine are used to maintain remission.
Further, the patient needs to modify their diet as it has been shown that crohns patients can develop
lactose intolerance which can cause inflammation and health maintenance must be maintained to
help keep the patient’s immune system functioning properly.

References

Buttaro, Terry M., amp, JoAnn Trybulski, amp, Patricia Polgar-Bailey, amp, Joanne Sandberg-Cook.
(2017). Primary Care: A Collaborative Practice.. [South University].

Epocrates.com, (2020). Crohn-Disease. Epocrates. Retrieved
from https://online.epocrates.com/diseases/4211/Crohn-disease/Key-Highlights

IBDClinic.ca, (2020) Smoking and Crohns Disease. How Does Smoking Affect Crohns Disease?
University of Alberta. Retrieved from http://www.ibdclinic.ca/ibd-and-lifestyle/smoking-and-
ibd/smoking-and-crohns-disease/

Peppercorn, M. & Kane, S. (2019). Clinical Manifestations, Diagnosis and Prognosis of Crohns Disease
in Adults. UpToDate. Retrieved from https://www.uptodate.com/contents/clinical-manifestations-
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diagnosis-and-prognosis-of-crohns-disease-in-adults?search=crohns%20disease
%20adult&source=search_result&selectedTitle=3~150&usage_type=default&display_rank=3#H1541
88516

Regueiro, M. & Hashash, J.A., (2019). Overview of the Medical Management of Mild (low risk) Crohn
Disease in Adults. UpToDate. Retrieved from https://www.uptodate.com/contents/overview-of-the-
medical-management-of-mild-low-risk-crohn-disease-in-adults?search=overview-of-the-
management-of-crohn-disease-
&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1#H2555882547
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