MosaicED Brain Teaser!
A 23 year old professional partier sees you in your GP clinic. Over the past 4 months he has had pus in his stool and had periods of diarrhoea. He has also noticed red lumps on his legs that a quite tender. A physical exam shows signs of anaemia and the inflammation described on his legs. You order a colonoscope and get some bloods. He is anaemic and ASCA positive. You have know idea what a professional partier is but think you may have messed up choosing med school if that was on the cards.
What is the most likely diagnosis?
- D-Coeliac Disease
- E-Crohn's Disease
- H-Irritable Bowell Syndrome
- I-Pancreatic Cancer
- K-Peptic ulcer
- L-Ulcerative Colitis
E-Crohn's Disease.Crohn’s can affect mouth to anus, skip lesions (normal bowel in between lesions) that are transmural. Transmural inflammation often leads to fibrosis causing obstruction. The transmural inflammation can cause perforations and fistulae. Crohn’s is much more likely to have extra GI manifestations; erythema nodosum, pyoderma gangrenosum, perianal lesions, uveitis or episcleritis. Often presents as chronic diarrhoea (less likely to be bloody), bloating, weight loss and fatigue (anaemia). Risk factors; family history, smoking, female, OCP, and being white.
On examination extra GI manifestations and non specific GI signs. 70% of people with Crohn's are ASCA positive. Important to test for Fe, B12 and folate. Where are they absorbed? Iron is absorbed mostly in the duodenum, B12 in the distal ileum, and folate in the jejunum. On colonoscopy skip lesions, cobblestoning, fistulae. On biopsy, 35% of the lesions will be non-caseating granulomas. Treat; antibiotics, immunotherapy, etc. Surgery is non curative, but 90% of people with crohn's will have 1 surgery in their lifetime, 50-70% will have >1. Surgery is only indicated when medical treatment failed
Remember: transmural, skip lesions, cobblestoning, ASCA, extra GI manifestations, vitamin deficiencies.