Snapshot A 18-year-old boy presents to his primary care physician for abdominal pain, diarrhea, and chronic fatigue. He reports that he has nonbloody diarrhea for the past few weeks. He could not identify any “bad” foods, and nobody else around him has the same symptoms. His aunt has a history of inflammatory bowel disease, but he is unsure which specific disease. He is noted to be underweight on physical exam. Laboratory results show elevated erythrocyte sedimentation rate (ESR) and C-reactive protein. He is scheduled for a colonoscopy with biopsy to confirm the diagnosis. Introduction Overview Crohn disease is an inflammatory bowel disease that can affect any part of the gastrointestinal (GI) tract, including the mouth and the anus characterized by abdominal pain and nonbloody diarrhea classically associated with non-contiguous involvement, or “skip lesions”, along GI tract Epidemiology demographics onset 15-30 years of age or 60-70s years of age risk factors family history Pathogenesis mechanism chronic Th1-mediated inflammation starts as focal inflammatory infiltrates around crypts, evolves into transmural inflammation and noncaseating granulomas Prognosis unpredictable course of relapses and remissions Presentation Symptoms GI symptoms results from transmural involvement abdominal pain bloody or nonbloody diarrhea abscess fistulas strictures malnutrition extraintestinal manifestations arthralgias kidney stones calcium oxalate ankylosing spondylitis gallstones due to poor bile acid absorption at the ileum systemic symptoms chronic intermittent fever weight loss fatigue Physical exam skin and mucosal findings pyoderma gangrenosum erythema nodosum aphthous stomatitis perianal region skin tags scarring ocular finding episcleritis uveitis Imaging Abdominal radiograph indications assess for bowel obstruction CT of abdomen indications evaluation for obstruction, fistulas, or abscesses Studies Serum labs serology used when endoscopic studies and barium studies are inconclusive anti-saccharomyces cerevisiae positive anti-neutrophil cytoplasmic antibody negative complete blood cell count elevated inflammatory markers Invasive studies colonoscopy or esophagogastroduodenoscopy indication diagnostic findings cobblestone mucosa skip lesions bowel wall thickening ulcers fissures Histology noncaseating granulomas lymphoid aggregates Differential Ulcerative colitis key distinguishing factors bloody diarrhea disease affecting colon and always the rectum mucosal and submucosal inflammation only Treatment Medical 5-aminosalicylic acid agents indications mild disease initial therapy drugs mesalamine best initial therapy sulfasalazine corticosteroids indications for flares immunosuppressive agents drugs infliximab good for those with fistula formation azathioprine recurrent symptoms off steroids antibiotics drugs metronidazole/ciprofloxacin perianal involvement anti-diarrheal medications drugs loperamide Surgical surgical resection of affected area indications not curative Complications Fistula formation Colorectal cancer Abscesses Strictures
QUESTIONS 1 of 5 1 2 3 4 5 Previous Next Lab Values Blood Hematologic Cerebrospinal Sweat, Urine, and BMI Blood, Plasma, Serum Reference Range ALT 8-20 U/L Amylase, serum 25-125 U/L AST 8-20 U/L Bilirubin, serum (adult) Total // Direct 0.1-1.0 mg/dL // 0.0-0.3 mg/dL Calcium, serum (Ca2+) 8.4-10.2 mg/dL Cholesterol, serum Rec: < 200 mg/dL Cortisol, serum 0800 h: 5-23 μg/dL //1600 h: 3-15 μg/dL 2000 h: ≤ 50% of 0800 h Creatine kinase, serum Male: 25-90 U/LFemale: 10-70 U/L Creatinine, serum 0.6-1.2 mg/dL Electrolytes, serum Sodium (Na+) 136-145 mEq/L Chloride (Cl-) 95-105 mEq/L Potassium (K+) 3.5-5.0 mEq/L Bicarbonate (HCO3-) 22-28 mEq/L Magnesium (Mg2+) 1.5-2.0 mEq/L Estriol, total, serum (in pregnancy) 24-28 wks // 32-36 wks 30-170 ng/mL // 60-280 ng/mL 28-32 wk // 36-40 wks 40-220 ng/mL // 80-350 ng/mL Ferritin, serum Male: 15-200 ng/mLFemale: 12-150 ng/mL Follicle-stimulating hormone, serum/plasma Male: 4-25 mIU/mL Female: premenopause: 4-30 mIU/mL midcycle peak: 10-90 mIU/mL postmenopause: 40-250 pH 7.35-7.45 PCO2 33-45 mmHg PO2 75-105 mmHg Glucose, serum Fasting: 70-110 mg/dL2-h postprandial:<120 mg/dL Growth hormone - arginine stimulation Fasting: <5 ng/mLProvocative stimuli: > 7ng/mL Immunoglobulins, serum IgA 76-390 mg/dL IgE 0-380 IU/mL IgG 650-1500 mg/dL IgM 40-345 mg/dL Iron 50-170 μg/dL Lactate dehydrogenase, serum 45-90 U/L Luteinizing hormone, serum/plasma Male: 6-23 mIU/mL Female: follicular phase: 5-30 mIU/mL midcycle: 75-150 mIU/mL postmenopause 30-200 mIU/mL Osmolality, serum 275-295 mOsmol/kd H2O Parathyroid hormone, serume, N-terminal 230-630 pg/mL Phosphatase (alkaline), serum (p-NPP at 30° C) 20-70 U/L Phosphorus (inorganic), serum 3.0-4.5 mg/dL Prolactin, serum (hPRL) < 20 ng/mL Proteins, serum Total (recumbent) 6.0-7.8 g/dL Albumin 3.5-5.5 g/dL Globulin 2.3-3.5 g/dL Thyroid-stimulating hormone, serum or plasma .5-5.0 μU/mL Thyroidal iodine (123I) uptake 8%-30% of administered dose/24h Thyroxine (T4), serum 5-12 μg/dL Triglycerides, serum 35-160 mg/dL Triiodothyronine (T3), serum (RIA) 115-190 ng/dL Triiodothyronine (T3) resin uptake 25%-35% Urea nitrogen, serum 7-18 mg/dL Uric acid, serum 3.0-8.2 mg/dL Hematologic Reference Range Bleeding time 2-7 minutes Erythrocyte count Male: 4.3-5.9 million/mm3Female: 3.5-5.5 million mm3 Erythrocyte sedimentation rate (Westergren) Male: 0-15 mm/hFemale: 0-20 mm/h Hematocrit Male: 41%-53%Female: 36%-46% Hemoglobin A1c ≤ 6 % Hemoglobin, blood Male: 13.5-17.5 g/dLFemale: 12.0-16.0 g/dL Hemoglobin, plasma 1-4 mg/dL Leukocyte count and differential Leukocyte count 4,500-11,000/mm3 Segmented neutrophils 54%-62% Bands 3%-5% Eosinophils 1%-3% Basophils 0%-0.75% Lymphocytes 25%-33% Monocytes 3%-7% Mean corpuscular hemoglobin 25.4-34.6 pg/cell Mean corpuscular hemoglobin concentration 31%-36% Hb/cell Mean corpuscular volume 80-100 μm3 Partial thromboplastin time (activated) 25-40 seconds Platelet count 150,000-400,000/mm3 Prothrombin time 11-15 seconds Reticulocyte count 0.5%-1.5% of red cells Thrombin time < 2 seconds deviation from control Volume Plasma Male: 25-43 mL/kgFemale: 28-45 mL/kg Red cell Male: 20-36 mL/kgFemale: 19-31 mL/kg Cerebrospinal Fluid Reference Range Cell count 0-5/mm3 Chloride 118-132 mEq/L Gamma globulin 3%-12% total proteins Glucose 40-70 mg/dL Pressure 70-180 mm H2O Proteins, total < 40 mg/dL Sweat Reference Range Chloride 0-35 mmol/L Urine Calcium 100-300 mg/24 h Chloride Varies with intake Creatinine clearance Male: 97-137 mL/minFemale: 88-128 mL/min Estriol, total (in pregnancy) 30 wks 6-18 mg/24 h 35 wks 9-28 mg/24 h 40 wks 13-42 mg/24 h 17-Hydroxycorticosteroids Male: 3.0-10.0 mg/24 hFemale: 2.0-8.0 mg/24 h 17-Ketosteroids, total Male: 8-20 mg/24 hFemale: 6-15 mg/24 h Osmolality 50-1400 mOsmol/kg H2O Oxalate 8-40 μg/mL Potassium Varies with diet Proteins, total < 150 mg/24 h Sodium Varies with diet Uric acid Varies with diet Body Mass Index (BMI) Adult: 19-25 kg/m2 Calculator ( ) xy AC 7 8 9 ÷ 4 5 6 × 1 2 3 - 0 . = + Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK Sorry, this question is for PEAK Premium Subscribers only Upgrade to PEAK You have 100% on this question. Just skip this one for now. Take This Question Anyway (M1.GI.15.8) A 22-year-old Caucasian female presents with severe right lower quadrant pain, malaise, and diarrhea. The physician performs an endoscopy and finds disease involvement in the terminal ileum, noting that the disease process is patchy with normal intervening mucosa. The entire wall of the region is thickened and inflamed, which may directly lead to formation of: Review Topic | Tested Concept QID: 101065 Type & Select Correct Answer 1 Fistulas 75% (49/65) 2 Toxic megacolon 6% (4/65) 3 Widening of the intestinal lumen 6% (4/65) 4 Plummer-Vinson syndrome 6% (4/65) 5 Paneth cell metaplasia 5% (3/65) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 1 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M1.GI.13.27) A 28-year-old Caucasian women with a 10 pack-year history of smoking presents with diarrhea and right, lower quadrant colicky pain. You note tender, red nodules on her shins. Radiograph imaging after barium study is shown in Figure A. What is the most likely diagnosis? Review Topic | Tested Concept QID: 101084 FIGURES: A Type & Select Correct Answer 1 Ulcerative colitis 7% (6/87) 2 Irritable bowel syndrome 2% (2/87) 3 Celiac disease 8% (7/87) 4 Hirschprung disease 3% (3/87) 5 Crohns disease 72% (63/87) L 2 Question Complexity D Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5 You have 100% on this question. Just skip this one for now. Take This Question Anyway (M1.GI.13.89) A 27-year-old female has a history of periodic bloody diarrhea over several years. Colonoscopy shows sigmoid colon inflammation, and the patient complains of joint pain in her knees and ankles. You suspect inflammatory bowel disease. Which of the following would suggest a diagnosis of Crohn disease: Review Topic | Tested Concept QID: 101146 Type & Select Correct Answer 1 Left lower quadrant pain 3% (6/204) 2 Jaundice 2% (5/204) 3 Loss of large bowel haustra 7% (14/204) 4 Mucosal and submucosal ulcerations 19% (39/204) 5 Perianal fistula 66% (135/204) L 2 Question Complexity E Question Importance Select Answer to see Preferred Response SUBMIT RESPONSE 5
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