Case 27: 8yo - Crohn's

Question 1

Functional Abdominal pain

• define:
• mechanism:
• sxs:
• dx:
• tx:

Answer 1

• define: pain without demonstrable evidence of pathologic condition (e.g. anatomic, metabolic, infectious, inflammatory, neoplastic) in children 4-18yo
• mechanism: enteric NS (for gut) fighting CNS ==> PAIN; abd bowel reactivity to physiologic stimuli / noxious stressful stimuli / psychological stress
• sxs: nonspecific abd pain, not life threatening +/- HA, difficulty sleeping, limb pain
• dx: chronic abd pain IF NO red flags on hx / exam, blood in stool
• tx: reassurance, close f/up, psychological eval

Question 2

most common cause of abd pain in school aged children

Answer 2

functional abd pain

Question 3

red flags in kids with abdominal pain

Answer 3

• involuntary weight loss
• deceleration of linear growth (FTT); slow weight gain
• GI blood loss
• significant vomiting
• chronic severe diarrhea
• persistent RUQ or RLQ pain
• unexplained fever
• FHx IBD

Question 4

timeline of changes in failure to thrive

Answer 4

1) slowing of weight gain, weight loss

2) drop in heigh velocity

Question 5

when is rectal exam helpful in a kid with abd pain?

Answer 5

• GI bleeding
• intussusception
• rectal abscess
• impaction
• for stool guiac exam

Question 6

common causes of microcytic anemia in kids with abdominal pain

Answer 6

1) iron deficiency d/t inadequate Fe intake; blood loss

2) thalassemia

Question 7

kiddo with abdominal pain. what would make you lean more toward possible crohn’s disease?

Answer 7

• fatigue
• pain that awakens her at night
• pain that can be localized
• involuntary weight loss / growth deceleration
• extraintestinal sxs = fever, rash, joint pain, aphthous ulcers, dysuria (arthritis, uveitis, renal involvement (kidney stones), hepatic involvement, and pyoderma gangrenosum)
• sleepiness after attacks of pain
• FHx of IBD (in 30%)
• abn labs == guaiac-positive stool, anemia, high plt, high ESR, hypoalbuminemia
• abnormalities in bowel fx == diarrhea, constipation, incontinence
• vomiting
• dysuria

PQRST AAA
follow up on pain for new/changing sxs

Question 8

how to grade IBD adult v. child

Answer 8

ADULT == Montreal

CHILD == Paris

• # of diarrhea stools/d
• daily abd pain ratings
• ratings of well-being
• presence of other sxs / findings related to Crohn’s dz
• abd fullness/palpable mass
• Hct
• height growth velocity
• weight

Question 9

diffdx of abdominal pain + bloody stools

Answer 9

USUALLY OCCULT BLOOD (v. grossly bloody stool)

• IBD **
• Celiac’s == b/w 6-24mo: chronic abd pain, abd distension, V/D, anorexia, poor weight gain +/- occult blood
• bacterial gastroenteritis (salmonella, shigella, yersinia, campylobacter, C. diff) == esp. common in pts with underlying colitis
• Giardiasis == acute/chronic; + travel hx; +/- weight loss, + occult blood
• peptic ulcer disease == guaiac-positive stools, WITHOUT DIARRHEA
• Henoch-Schonlein purpura == abd pain within days of palpable purpura, lasting weeks-months, +/- guaic-positive stool v. massive GI bleeding (d/t intussusception), WITHOUT FTT

Question 10

most common intestinal parasite in US

Answer 10

Giardia lamblia

Question 11

kiddo presents with gross bloody stool. is it likely to be giardia?

Answer 11

not really == usually occult blood

other parasites are more likely to cause grossly bloody stools(entamoeba)

Question 12

lab evaluation of abdominal pain + bloody stools

Answer 12

• CBC with differential == evaluate anemia; elevated plt (= nonspecific marker of inflammation)
• ESR, CRP == for inflammation (esp. IBD)
• LFTs == low protein, albumin for malnutrition, hepatic dz and poor synthetic fx, protein-losing enteropathy
• IgA TTG (or IgA antiendomysial antibodies) == celiac dz
• C diff stool toxin test == can be cause / first sign of IBD
• stool ova / parasites (or Giardia-specific antigen testing) == for chronic abd pain with few other sxs
• stool culture == for bacterial gastroenteritis

Question 13

relationship of C. diff and IBD

Answer 13

• in immunocompetent hosts==> usually d/t exposure to antibiotics
• also common in pts with underlying colitis

Question 14

evaluation of IBD

Answer 14

1) upper endoscopy and colonoscopy with biopsy
- distinguish b/w UC and Crohns
- UC == generalized, mucosal/submucosal inflammation; in colon + rectum; crypst abscesses
- Crohn’s == patchy, full-thicness, from mouth to anus, +/- fistula

2) CT/MRI for small bowel disease ==> to map disease location, assess severity and identify complications
- Crohn’s == involvement from mouth to anus
- UC == can have “backwash ileitis”

Question 15

treatment of crohn’s disease

Answer 15

GOAL

1) eliminate sxs and improve QoL
2) restore normal growth
3) eliminate complications

TREATMENT

1) induction for remission [corticosteroids > 15w, enteral nutrition therapy] ==> down-regulate production of inflammatory cytokines, nuclear factor-kappa B production
2) maintenance for baseline [immunomodulators - thiopurines, methotrexate, anti-TNF]

if med-refractory == surgery

Question 16

is aspirin (mesalamine) helpful in crohn’s for pediatric patients?

Answer 16

NO = no evidence for efficacy in crohn’s in kids

helpful in adults with UC

Question 17

typical presentation of an isolated rectal fissure

- what if it had mucus mixed in?

Answer 17

stool with streaks of superficial blood; mucus is absent from the stool

==> if mucus is mixed in –> likely more of a colonic problem

Question 18

what would you expect on labs in microcytic anemia in kids?

Answer 18

==> low iron, blood loss, lead poisoning

• low reticulocyte count
• low iron levels
• high iron binding capacity

Question 19

what would you expect on labs in normocytic anemia in kids?

Answer 19

==> lead poisoning, anemia d/t marrow failure, anemia of chronic disease

• low reticulocyte count

Question 20

Which of the following studies would be most helpful in confirming the diagnosis of IBD? Select the two studies that would be the most helpful.

 Multiple Choice Answer:
A		Abdominal CT scan	
B		Upper endoscopy	
C		Barium enema	
D		Colonoscopy	
E		Perinuclear anti-neutrophil antibody (p-ANCA)	
F		Trial of treatment with steroids

Answer 20

upper endoscopy + colonoscopy

A trial treatment with steroids (F) is not appropriate without first making a diagnosis (b/c would need to give it for >15d for it to be effective)

Question 21

IBD

• epidemiology:
• prognosis:
• causes:

Answer 21

• epidemiology: peak <20yo (5% <10yo)
• prognosis: majority progress to relapsing and chronic dz
• causes: FHx (Crohn’s > UC); infectious, immunologic

Question 22

A 2-year-old female is brought to the ED by her mother because of increasingly frequent abdominal pain. She has been experiencing this pain on and off for the past year, along with increasing abdominal distention, vomiting, and diarrhea. You chart her height and weight, and find that she is below the 5th percentile for both. IgA tissue transglutaminase (TTG) antibody returns positive. What is the best treatment for this patient?

 Single Choice Answer:
Please select one answer.  
A		Antibiotic treatment	
B		Gluten-free diet	
C		Corticosteroids	
D		Pain management	
E		Metronidazole

Answer 22

B

A gluten-free diet is the best way to manage celiac disease. Celiac disease can present with chronic abdominal pain, vomiting, abdominal distention, and diarrhea. Growth failure can result from malabsorption or anorexia. Anemia may also result from occult GI bleeding, although frank blood in the stool is rare. The IgA tissue transglutaminase antibody titer is a very sensitive and specific test for this disease.

Question 23

An 11-year-old male comes to the clinic with a chief complaint of abdominal pain for three months. The pain is not associated with eating. Sometimes he feels full and nauseated, along with the pain, but then it resolves on its own. He denies diarrhea, vomiting, and bloody stools. His mother is primarily concerned because his abdominal pains cause him to miss school quite often now. ROS is otherwise negative and the only pertinent issue is his pain. When you evaluate his growth curves, he is progressing at the 60th percentile for height and weight and you do not notice a change since birth. Through a social history you ascertain that he is quite intelligent and has recently been advanced to 7th grade from 5th grade. Vital signs are within normal limits for his age and physical exam (including rectal and genital) are unremarkable. Stool sample was sent in anticipation of today’s visit and was negative for occult blood. What is the most likely cause for his abdominal pain?

 Single Choice Answer:
Please select one answer.  
A		Functional abdominal pain	
B		Inflammatory bowel disease	
C		Bacterial gastroenteritis	
D		Peptic ulcer disease	
E		Meckel's diverticulum

Answer 23

A

pain + fullness + nausea

still doing well in development and school

Functional abdominal pain would be the most likely diagnosis in this setting at this time. History in this setting is not suggestive of any other diagnosis directly causing his abdominal pain, except a change in his social setting. For better understanding of the nature of this child’s pain, it would be best to talk to him alone, without his mother present, to determine if he is having trouble adjusting to school and to assess whether he has a stable home environment. His pain is chronic, with no other symptoms (diarrhea, bloody stools, growth failure), making a functional issue most likely.

Question 24

8-year-old Jenny presents complaining of intermittent, crampy abdominal pain that has persisted over the last three months. The pain is nonspecific, nonfocal, and not associated with any other systemic symptoms such as fever, chills, weight loss, nausea, vomiting or diarrhea. The pain also seems to occur more frequently during the week and not as often on weekends. The abdominal exam is normal. Jenny is given a diagnosis of functional abdominal pain and scheduled for a one-month follow-up. Six months later, she returns to the clinic complaining of more frequent, more severe abdominal pain that is waking her up at night. She also reports a week of diarrhea containing mucus and blood without associated fever or vomiting. Review of her growth chart demonstrates a slowing of weight gain and a drop in height velocity. What is the most likely diagnosis?

 Single Choice Answer:
Please select one answer.  
A		Irritable bowel syndrome	
B		Giardiasis	
C		Celiac disease	
D		Crohn's disease	
E		Henoch-Schonlein purpura (HSP)

Answer 24

D

more frequently during the week (at school?)

waking up at night
bloody & mucus stools

Giardia == would have had a history for it

Celiac == not really blood, +/- dermatitis hepretiformis

HSP== would have a rash, then abd pain 3d later

Crohn’s disease is most consistent with this presentation, as it affects GI tract from mouth to anus, leading to abdominal pain, diarrhea (can be bloody), vomiting, or weight loss. Extraintestinal symptoms include skin rashes, arthritis, and fatigue. Fever, fistula, and perianal complications are also common.

Question 25

Kenny is a 12 year-old male who comes to your clinic with a chief complaint of crampy abdominal pain. His mother tells you that sometimes he wakes up from sleep due to the pain. He also has diarrhea that sometimes has blood in it. When asked about stressors in his life, his mother sighs and tells you that she is recently divorced and had to move Kenny to a new school. On physical exam, he appears small for his age. Abdomen is soft, non-distended, but tender to palpation at the RUQ. On rectal exam, you note anal skin tags and an anal fistula. Skin exam shows red tender nodules on his shins. Labs show a microcytic anemia. What is the next best step in management?

 Single Choice Answer:
Please select one answer.  
A		Reassure and refer to psychiatry	
B		Start omeprazole and antibiotics	
C		Colonoscopy	
D		Start mesalamine	
E		Obtain IgA endomysial antibody and IgA anti-tissue transglutaminase antibody

Answer 25

C

wake from sleep
occult blood
small for age
RUQ pain
anal skin tags + anal fissue
microcytic anemia (chronic dz)

Colonoscopy is the best answer. Kenny likely has IBD (Crohn’s disease or ulcerative colitis [UC]). He has crampy abdominal pain and intermittently bloody diarrhea, crampy abdominal pain (that wakes him up at night), perianal disease, and erythema nodosum. He also has microcytic anemia, likely from chronic blood loss. Colonoscopy with biopsies will allow you to diagnose Crohn’s disease (or UC) prior to treating it. The diagnosis begins with a colonoscopy to obtain tissue biopsies as well as blood tests (p-ANCA, ASCA).

Obtain IgA endomysial antibody and IgA anti-tissue transglutaminase antibody is incorrect. This is the right diagnostic test for celiac disease. However, celiac disease would not present with blood in the stool or other extraintestinal signs. Celiac can be associated with dermatitis herpetiformis, an itchy, papulovesicular rash.