NMS. Casos Clínicos

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Part II ♦ Specific Disorders

Case 8.8 Crampy Abdominal Pain in Patient with Crohn Disease You are asked to see a 24-year-old in the emergency department with crampy ab- dominal pain, nausea, and vomiting. Past history is significant for a 2-year history of Crohn disease of the terminal ileum. The patient initially received treatment with ste- roids and has been in remission on no steroids for 6 months. The patient’s abdomen is distended, and the obstructive series is compatible with a small bowel obstruction . There is no fever or localized pain and no signs of complications, including no acidosis and only a mild leukocytosis (WBC count = 13,000/mm 3 ). Q: What is the most likely diagnosis? A: The suspected diagnosis is a small bowel obstruction secondary to a stricture of the bowel involved with Crohn disease . Crohn disease shares some similarities with ulcerative colitis (Table 8-1). Table 8-1: Inflammatory Disease of the Colon: Characteristics of Crohn Disease and Ulcerative Colitis Characteristics Crohn Disease Ulcerative Colitis Usual location Any segment of colon; ileocolic disease is most common. Rectum, left colon, or entire colon

Continuous disease: ~50% involves rectum only, half is pancolitis, 10%–20% involve terminal ileum. Mucosal disease: epithelial ulceration and crypt abscesses Rectal bleeding Bowel stricture rate; should raise suspicion of cancer No perianal disease

Anatomic and clinical features

Segmental distribution, skip areas Inflammation with deep fissures Thickened bowel wall, fibrous strictures Abscesses, fistulas Common, continuous rectal bleeding Noncaseating granulomas Mesenteric lymphadenopathy

Focal aphthous ulcers Deep ulceration with cobblestone appearance Strictures Perianal disease SAMPLE Radiologic features Upper gastrointestinal series with small bowel follow-through Enteroclysis study shows “string sign”—narrowing of terminal ileum from edema. Steroids for acute flare-ups Immunosuppressive drugs Metronidazole for perianal disease Mucosal ulcerations with islands of intact mucosa (pseudopolyps) Medical management Steroids for acute disease 5-aminosalicylic acid for prevention of relapse

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