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Julie Vajnar, PA-C, RT, DEPARTMENT EDITOR

GI symptoms in a 34-year-old woman

Julie Vajnar, PA-C, RT

The author practices in a radiology group at North Oaks Health System, Hammond, La. She has indicated no relationships to disclose relating to the content of this article.

CASE

The patient is a 34-year-old white woman with abdominal pain, nausea, vomiting, and blood in stool. On physical examination, mild tenderness is present in the right lower quadrant of the abdomen. There is no abdominal distention or evidence of ascites. Murphy’s sign is negative. No bruits are heard. No palpable masses, hepatomegaly, or splenomegaly is noted.

A stool guaic test is positive for blood and the WBC count is mildly elevated, but the results of laboratory studies are otherwise normal. An ESR is not performed. The differential diagnosis in this patient includes Crohn’s disease and ulcerative colitis—both types of inflammatory bowel disease (IBD)—as well as irritable bowel syndrome, appendicitis, and pelvic inflammatory disease. CT of the abdomen and pelvis is performed (see Figure 1), as is an upper GI series with small bowel follow-through (see Figure 2). What do these imaging studies reveal?

DISCUSSION

The CT shows circumferential thickening of the small bowel in the region of the terminal ileum with inflammation of the surrounding mesenteric fat. The small bowel follow-through shows a long segment of terminal ileum with circumferential narrowing and ulceration. Given the patient’s age and symptoms, these findings are most compatible with Crohn’s disease. The inflammatory changes in the bowel involve the terminal ileum, which is the area most commonly affected by Crohn’s disease.

The etiology of this chronic, inflammatory process of the alimentary tract is unknown, but an abnormal response of the immune system is suspected to be the culprit. Unlike ulcerative colitis, which is the other type of IBD, Crohn’s disease can develop anywhere from the mouth to the anus; ulcerative colitis is confined to the colon. Crohn’s disease affects the colon and terminal ileum in approximately 55% of cases, the small bowel only in 30%, and the colon alone in about 15%. Crohn’s disease is also different from ulcerative colitis in that it affects all layers of the intestine, whereas ulcerative colitis affects only the mucosa and submucosa. Both forms of IBD are usually diagnosed in the second and third decades of life, but they can also develop in older patients. Crohn’s disease is rare in children. Ulcerative colitis is usually seen in a continuous distribution, whereas Crohn’s disease can produce skip lesions, meaning areas of normal bowel occurring between segments of abnormal bowel. Ulcerations of the bowel seen in Crohn’s disease often have an appearance that resembles a cobblestone street.

The incidence of Crohn’s disease is higher in Northern European Jews and whites. It affects females more than males and tends to be seen more in developed countries. Causes of death in patients with Crohn’s disease include peritonitis with sepsis, malignancy, thrombus formation, and surgical complications. IBD tends to run in families, particularly among siblings: Someone with an affected brother or sister has a risk of developing Crohn’s disease that may be 30 times greater than normal.

Symptoms of Crohn’s disease include crampy abdominal pain, diarrhea, rectal bleeding, fever, weight loss, and loss of appetite. The disease can affect other systems as well, including the joints, eyes, skin, or liver. Children may have delayed growth and sexual development. The symptoms of Crohn’s disease often come and go, with periods of worsening and remission. There is no known cure.

During flare-ups, complications such as intestinal obstruction or bleeding, fistula or abscess formation, and malnutrition may occur. Nausea, vomiting, and abdominal distention may be seen with obstruction. The most commonly seen fistulas in Crohn’s disease are connections between the bowel and the vagina, skin, or urinary bladder. Bowel contents may then be expelled into the vagina or bladder or through an opening in the skin. Medical therapy may improve these complications, but sometimes surgery is required to treat obstruction, fistulas, or abscesses. Perforation is rare but may occur. Malnutrition can be treated with supplementation. The deficiencies are usually of proteins, calories, and vitamins and minerals.

In patients with Crohn’s disease, laboratory studies may show anemia, leukocytosis, an elevated ESR, hypokalemia, hypoalbuminemia, or blood in the stool. Diagnosis can be aided by barium studies, CT, and endoscopy and biopsy. Video capsule endoscopy is a recently introduced method for evaluating the intestines; a capsule containing a small video camera is swallowed, and images of the alimentary tract are taken and then downloaded on a computer. This modality may be able to detect early changes associated with Crohn’s disease that would not be seen with a barium study. Video capsule endoscopy is not offered everywhere and should not be done if the patient has symptoms of obstruction.

The goal of therapy for Crohn’s disease is to suppress the inflammatory response. The available treatments include aminosalicylates, corticosteroids, immune modifiers, antibiotics, and biologic therapies (eg, infliximab). Emotional support is also an important part of therapy. Patients should be encouraged to join a local support group where they can interact with other people who live with IBD.