Case 27

Question 1

What are key history findings in an 8 yr old patient with Crohn’s disease?

Answer 1

Diarrhea, Growth failure and Bloody stools

Question 2

What are key findings on physical exam in an 8 yr patient with Crohn’s disease?

Answer 2

Rectal fissure

Question 3

What is on the differential diagnosis with Crohn’s Disease?

Answer 3

Inflammatory bowel disease, Celiac disease, Functional abdominal pain, peptic ulcer disease, giardiasis, constipation, bacterial diarrhea, henoch-schonlein purpura

Question 4

What are key findings from testing for Crohn’s disease?

Answer 4

Heme-positive stools. Mild microcytic anemia.

Question 5

What are the main causes of abdominal pain in children?

Answer 5

• Functional (or chronic recurrent) abdominal pain
• Constipation
• Peptic ulcer disease, lactose intolerance, inflammatory bowel disease

Question 6

Functional (or chronic recurrent) abdominal pain:

Answer 6

• Most common cause of abdominal pain in all ages of children
• Usually nonspecific and not life-threatening
• May be categorized as one or a combination of the following:
• -Functional dyspepsia
• -Irritable bowel syndrome
• -Abdominal migraine
• -Functional abdominal pain syndrome
• Generally can be diagnosed correctly by the PCP in children 4-18 yo with chronic abdominal pain when there are no alarming symptoms or signs, the PE is normal and the stool sample tests are negative for occult blood, without the requirement of additional diagnostic evaluation.
• Children with functional abdominal pain may have additional somatic complaints, such as headache, difficulty sleeping or limb pain.
• Tx generally consists of reassuring the parents and patient that no serious illness is present
• Functional abdominal pain may be difficult for the child and family to deal with and must be followed closely.

Question 7

Constipation:

Answer 7

Common cause of abdominal pain, but - in the absence of abnormal stools - less common than functional abdominal pain.

Question 8

Peptic ulcer disease, lactose intolerance, inflammatory bowel disease:

Answer 8

These are much less common than either functional abdominal pain or constipation.

Question 9

Inflammatory bowel disease (IBD):

Answer 9

Includes both Crohn’s disease (CD) and ulcerative colitis (UC). Because the definitions of UC and CD are based on the location and characteristics of the inflammatory process within the GI tract, evaluation for IBD involves looking for inflammation in both upper and lower GI tract.

Question 10

Ulcerative colitis:

Answer 10

• Relatively generalized inflammation is confined to the mucosa, starting in the rectum and involving a variable extent of colon proximally
• Crypt abscesses are common
• Rarely, patients may have discontinuous inflammation at diagnosis or even relative rectal sparing. Over the course of the illness, however, the inflammation becomes more confluent.

Question 11

Crohn’s disease:

Answer 11

• The inflammation associated with CD may involve any portion of the alimentary tract, from mouth to anus.
• Mucosal inflammation may become more generalized or remain patchy and may extend gradually into the submucosa, muscularis and serosa.
• Transmural inflammation can result in fistula formation.

Question 12

What are red flags for Crohn’s disease?

Answer 12

• Pain that awakens the child at night
• Pain that can be localized
• Involuntary weight loss or growth deceleration
• Extraintestinal symptoms such as fever, rash, joint pain, aphthous ulcers, or dysuria
• Sleepiness after attacks of pain
• Positive family history of inflammatory bowel disease (although positive in only about 30 percent of patients)
• Abnormal labs (eg heme positive stool, anemia, high platelet count, high ESR, or hypoalbuminemia)
• Abnormalities in bowel function (diarrhea, constipation, incontinenece)
• Vomiting
• Dysuria

Question 13

Diagnosis of Inflammatory bowel disease:

Answer 13

Definitive diagnosis of either Crohn’s disease or ulcerative colitis is established with a combination of radiography and endoscopy. It is important to make the distinction, because treatment and prognosis of the two disorders is not the same.

Question 14

Assessment of growth and development with Crohn’s disease:

Answer 14

• Imp. to plot growth parameters on a growth chart and follow over time
• Slowing of weight gain (or weight loss) may be one of the first signs of chronic illness
• A drop in height velocity is much less common and suggests a more longstanding illness

Question 15

Rectal exam:

Answer 15

• Not necessary in all pediatric patients with abdominal pain
• Can aid in the diagnosis of gastrointestinal bleeding, intussusception, rectal abscess, or impaction.

Question 16

Grading severity of Crohn’s disease:

Answer 16

Severity of disease may be graded using the Crohn’s Disease Activity Index (CDAI). This index includes the number of diarrheal stools per week, the daily abdominal pain ratings, ratings of well being, the presence of other symptoms or findings related to Crohn’s disease, abdominal fullness/palpable mass, hematocrit, and weight.

Question 17

What is on the differential diagnosis with Inflammatory bowel disease?

Answer 17

Celiac disease, Bacterial gastroenteritis, Peptic ulcer disease (PUD), Giardiasis, HSP, Functional abdominal pain, Constipation, Meckel’s diverticulum.

Question 18

Inflammatory bowel disease:

Answer 18

• Pain can be severe and acute, or mild and subacute
• Often presents with growth failure
• Bloody stools strongly suggests IBD
• Two types of IBD: Crohn’s Disease and Ulcerative Colitis

Question 19

Celiac disease:

Answer 19

Uncommon but under diagnosed cause of abdominal pain and growth failure.

• Classic presentation of celiac disease occurs between 6-24 months of age with chronic abdominal pain, abdominal distention, diarrhea, anorexia, vomiting and poor weight gain
• Celiac disease can present with occult blood loss leading to anemia; gross blood per rectum is unusual.
• Presentation is quite variable, and diagnosis is often delayed due to the lack of classic symptoms

Question 20

Bacterial gastroenteritis:

Answer 20

• Relatively common
• Gastroenteritis of bacterial origin (eg, Salmonella, Shigella, Yersinia, Campylobacter, Clostridium difficile) generally presents with acute bloody diarrhea, often with abdominal pain.

Question 21

Peptic Ulcer Disease (PUD):

Answer 21

Uncommon in children, but important to consider with recurrent abdominal pain and guaiac-positive stools (occult blood).

Question 22

Giardiasis:

Answer 22

• Most common intestinal parasite in this country
• Uncommon cause of chronic abdominal pain
• Typically presents with watery diarrhea
• Giardia infection can be acute or chronic
• Bloody stools less likely with parasitic causes of diarrhea
• Most patients do not have weight loss
• Travel history would increase or decrease level of suspicion

Question 23

Henoch-Schonlein Purpura (HSP):

Answer 23

Presents with GI sx in most cases.

• Colicky abdominal pain and bloody stools common, but diarrhea is not
• Pain can develop within days of the purpuric rash and can last weeks to months
• 50 percent of patients with HSP have guaiac-positive stools; less commonly, there can be massive GI bleeding.

Question 24

Functional abdominal pain:

Answer 24

Diagnosis of exclusion that should not present with associated abnormalities.

Question 25

Constipation:

Answer 25

Very common cause of chronic abdominal pain.

• Diarrhea not expected with constipation
• Abdominal mass typically felt
• Bloody streaks may be seen on the stools or cause a positive stool guaiac

Question 26

Meckel’s diverticulum:

Answer 26

• Often asymptomatic

- Usually painless

Question 27

Stool guaiac:

Answer 27

Detects presence of blood in the stool

Question 28

CBC:

Answer 28

W/ a history of bloody stools and pallor, important to determine if patient is anemic (Also, platelets are a nonspecific marker of inflammation)

• In children, microcytic anemia (dec. RBC production) is most often due to iron deficiency. Iron deficiency may be due to either inadequate iron intake or loss of blood. In a patient with abdominal pain and heme-positive stools, anemia would first be considered a sign of blood loss.
• Hemolytic anemias, such as glucose-6-phosphatase dehydrogenase (G6PD) deficiency, result from increased RBC destruction

Question 29

Hepatic function tests:

Answer 29

Low protein and albumin levels may reflect malnutrition, hepatic disease with poor synthetic function, or losses from a protein-losing enteropathy.

Question 30

IgA tissue transglutaminase (TTG) antibody:

Answer 30

Sensitive and specific test for celiac disease (gold standard is small bowel biopsy showing villous atrophy).

Question 31

Stool ova and parasites:

Answer 31

Intestinal parasites can occasionally cause abdominal pain with few other symptoms. Giardia-specific antigen testing is available and is a better diagnostic test for this organism than ova and parasite testing.

Question 32

Clostridium difficile toxin assay:

Answer 32

C. difficile is more common in patients with underlying colitis. (In immunocompetent patients, more likely to follow antibiotic exposure)

Question 33

Upper GI tract series with small bowel follow-through and colonoscopy:

Answer 33

An upper GI tract study with small bowel follow-through and colonoscopy are appropriate diagnostic tests to make the distinction between UC and CD. In some centers, an upper endoscopy would be done as well.

Question 34

Barium enema:

Answer 34

• Several characteristic findings in CD (eg cobblestoning, ulceration) may be helpful in making the diagnosis or defining extent/complications of the disease (eg, strictures, fistulas).
• However, the contrast will temporarily delay colonoscopy (which is a more definitive diagnostic study)
• There is also an association between barium enema and increased risk of toxic megacolon in patient with UC
• At most academic centers, a barium enema would be done only after a colonoscopy (if at all).

Question 35

Management of Crohn’s Disease (treatment):

Answer 35

There are many therapeutic options for patients with CD, including medications, surgery, nutritional rehabilitation, and psychological support. This is one reason that CD patients are often managed by a pediatric gastroenterologist and multidisciplinary team.

• Management is based on severity of disease at time of diagnosis
• First-line treatment for mild-moderate CD is mesalamine (5-aminosalicylic acid).
• If patient has an incomplete response, may also try:
• -Steroids (prednisone; budesonide)
• -Antibiotics (ciprofloxacin and metronidazole)
• -Immunomodulators (azathiprine, 6-mercaptopurine, methotrexate, and cyclosporine)
• -Monoclonal antibody to TNF-alpha (infliximab or Remicade)

Question 36

Extra intestinal manifestations of Crohn’s disease:

Answer 36

Obtain studies to look for associated findings of Crohn’s disease, such as arthritis, uveitis, renal involvement (kidney stones), hepatic involvement, and erythema nodosum.