Please reply to the following discussion with one or more references. Participate in the discussion by asking a question, providing a statement of clarification, providing a point of view

Jessica Alper Discussion

Differential diagnosis

Crohn’s Disease is classified as a type of chronic inflammatory bowel disease (IBD), leading to digestive disorders including inflammation of the digestive system. Some factors associated with it are geographical location, inappropriate diet, genetics, as well as inappropriate immune responses (Seyedian et al., 2019). Crohn’s disease can mimic other types of diseases, which can make it difficult to diagnose. Symptoms associated with this condition include pain, diarrhea, fever and more. It usually affects the mouth, anus, and the entire layers of the intestines. 

The first differential diagnosis is Ulcerative Colitis (UC), which is another type of IBD and can also lead to inflammation of the gastrointestinal tract. Symptoms associated with UC include diarrhea, abdominal pain, rectal bleeding, as well as weight loss. Symptoms are typically “limited to the colon and is found mostly in some parts of the large intestine including colon and rectum” (Seyedian et al., 2019). 

The second differential diagnosis is celiac disease. Caio et al. (2019) state that this condition is autoimmune, and it is “characterized by a specific serological and histological profile triggered by gluten ingestion in genetically predisposed individuals”. Gluten is described as a protein that is alcohol-soluble and presents in several cereals, such as wheat, rye, barley, spelt and more. Symptoms include diarrhea, fatigue, weight loss, bloating, gas, abdominal pain, nausea, and vomiting. 

The third differential diagnosis for this condition is diverticulitis, which is defined as an inflammation of the diverticulum in the colon. It can be either acute or chronic, and it is most specifically described as an “obstruction of the diverticulum sac by fecalith, which by irritation of the mucosa causes low-grade inflammation, congestion and further obstruction” (Rezapour et al., 2017). Multiple factors can contribute to this disease, such as colonic wall structure, colonic motility, genetics, fiber intake, vitamin D levels, obesity, as well as physical activity. 

Physical exam findings

When examining a patient with Crohn’s disease, it is important to focus on a few different factors, such as temperature, weight, nutritional status, presence or absence of abdominal tenderness or a mass, perianal along with rectal examination findings, additionally to extraintestinal manifestations (Ghazi, 2019). Some findings from the physical assessment can vary from fullness to discrete masses, especially in the right lower quadrant of the abdomen, which typically involves the ileal part of the colon. Other masses may be felt due to the thickened or matted loops of the inflamed bowels. 

Upon assessing the perianal area, more information can be provided to increase the suspicion of the inflammatory bowel disease. Skin tags, fistulae, ulcers, abscesses, and scarring may be noted. Additionally, performing a rectal examination can help assess the sphincter tone and gross abnormalities of the rectal mucosa can be observed. Other extraintestinal manifestations may be noted with Crohn’s disease, such as the skin, joints, mouth, eyes, liver, or bile ducts, and especially arthritis and arthralgia. Lastly, “examination of the skin and oral mucosa may show mucocutaneous or aphthous ulcers, erythema nodosum, and pyoderma gangrenosum” (Ghazi, 2019). Other signs include pallor in anemic patients, jaundice in patients with liver disease with cholestasis, as well as episcleritis. 

Diagnostic testing

The diagnosis of Crohn’s disease can be made based on the clinical, laboratory, histologic and radiologic findings. Several procedures may be performed to confirm the diagnosis. 

Performing a colonoscopy is the test of choice in order to assess the disease activity in patients with this condition. An alternative option is to perform complementary cross-sectional imaging to assess the phenotype. An upper gastrointestinal (GI) endoscopy and histologic examination may be recommended when the colonoscopy is “unable to definitely diagnose Crohn’s disease or in the presence or upper GI symptoms” (Ghazi, 2019). Ordering plain radiography or CT scan of the abdomen may also be used to assess for any bowel obstructions. They can also be used to assess the pelvis for any type of intra-abdominal abscesses. CT enterography or MRI can now replace the small bowel follow-through studies, as they help better differentiate between inflammation and fibrosis. Lastly, an MRI of the pelvis or endoscopic ultrasounds can help assess for perianal fistulae and may also help detect the presence of pelvic or perianal abscesses. 

Additionally to diagnostic tests, some laboratory values might help narrow down the diagnosis of Crohn’s disease. CRP and ESR can be associated with complications of the condition. The full diagnosis is made by endoscopic visualization and biopsy, especially a “colonoscopy with intubation of the terminal ileum that is used to evaluate the extend of the disease, to demonstrate strictures and fistulae, and to obtain biopsy samples to help differentiate the process from other inflammatory, infectious, or acute conditions” (Ghazi, 2019). 

Treatment Plan

It is important to note that the treatment of Crohn’s disease is based on the disease site, the pattern, the activity as well as the severity. One specific goal of treatment includes achieving “the best possible clinical, laboratory, and histologic control of the inflammation disease with the least adverse effects from medication” (Ghazi, 2019). Another goal is to allow the patient to properly function on a daily basis, as well as promoting growth with adequate nutrition in children. 

Veauthier and Hornecker (2018) state that the management of Crohn’s disease aims at first treating the inflammatory process along with the associated complications, while achieving and maintaining remission. Antibiotics should be limited to treating complications, such as abscesses and fistulas. Some medication treatments include prescribing corticosteroids, immunomodulators as well as biologics. Corticosteroids typically includes tapering courses of prednisone, starting with 40 to 60mg based on the severity of the symptoms, and decreasing by 5 mg until 20mg is reached, then decreasing by 2.5 to 5mg until discontinuation is achieved. As far as immunomodulators, thiopurines and methotrexate can be used to induce remission. Monoclonal antibodies, such as anti-TNF agents, anti-integrin agents and anti-interleukin antibody therapy may help induce remission and should be continued for maintenance. Depending on the severity of the symptoms and the disease process, early resection may be an option if the disease is limited to the ileocecal region (Veauthier & Hornecker, 2018). 

References

Caio, G., Volta, U., Sapone, A., Leffler, D. A., De Giorgio, R., Catassi, C., & Fasano, A. (2019). Celiac disease: A comprehensive current review. BMC medicine, 17(1), 142.  https://doi.org/10.1186/s12916-019-1380-z

Ghazi, L. J. (2019). Crohns disease clinical presentation. Medscape.  https://emedicine.medscape.com/article/172940-clinical#b3

Rezapour, M., Ali, S., & Stollman, N. (2018). Diverticular disease: An update on pathogenesis and management. Gut and liver, 12(2), 125–132.  https://doi.org/10.5009/gnl16552

Seyedian, S. S., Nokhostin, F., & Malamir, M. D. (2019). A review of the diagnosis, prevention, and treatment methods of inflammatory bowel disease.  Journal of medicine and life,  12(2), 113–122.  https://doi.org/10.25122/jml-2018-0075

Veauthier, B., & Hornecker, J. R. (2018). Crohn's disease: Diagnosis and management. American Family Physician, 98(11), 661-669.

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