A 25-year-old woman is evaluated for a 1-month history of intermittent, loose, bloody bowel movements associated with pain in the left lower quadrant before defecation. The bleeding occurs with and without bowel movements. She reports no fever, chills, night sweats, arthralgia, eye pain, or rash. The patient works in a day care center and has not traveled or used antibiotics recently. She takes no medication.
On physical examination, vital signs are normal. The abdomen is scaphoid and soft, with suprapubic tenderness. The remainder of the physical examination is normal.
Stool testing for bacterial enteropathogens, including Clostridium difficile, is negative.
Colonoscopy results show patchy erythema and ulceration in the cecum, ascending colon, descending colon, and sigmoid colon with no involvement of the transverse colon or rectum. Mucosal biopsies of the involved mucosa reveal distorted and branching colonic crypts with lymphocytic and neutrophilic infiltration. Ileal examination is normal.
Which of the following is the most likely diagnosis?
A. Crohn disease
C. Microscopic colitis
D. Ulcerative colitis
MKSAP Answer and Critique
The correct answer is A. Crohn disease. This content is available to MKSAP 18 subscribers as Question 38 in the Gastroenterology and Hepatology section. More information about MKSAP is available online.
The patient has Crohn colitis presenting as a chronic inflammatory diarrhea. Common symptoms are abdominal pain, diarrhea, and weight loss; overt gastrointestinal bleeding is a less common manifestation. Crohn disease has varied presentations that can make diagnosis difficult. The pattern of inflammation and histologic features in this case allow distinction of Crohn disease from other inflammatory conditions. Colonoscopy findings are consistent with Crohn colitis based on patchy distribution of mucosal inflammatory changes with normal intervening mucosa, called “skip areas.” The biopsy results show distorted and branching colonic crypts, which are indicative of chronic colitis. The skip areas of normal intervening mucosa and biopsy results for involved mucosa showing features of chronicity (distorted and branching colonic crypts) make Crohn disease the most likely diagnosis.
The patient is at risk for Giardia lamblia infection because she works in a child care center. However, Giardia is a small-bowel protozoal pathogen and does not cause the symptoms of colonic inflammation with bloody diarrhea. Although most patients with giardiasis are asymptomatic, those with symptoms note abdominal pain and cramping with diarrhea, often consisting of large-volume, watery, and foul-smelling stools. Symptoms may be acute or chronic.
Microscopic colitis does not cause bloody diarrhea but rather is a cause of chronic watery diarrhea predominantly in women, with a peak onset between ages 60 and 70 years. Also, colonoscopy results are normal in patients with this condition, with inflammation only seen on biopsy.
Ulcerative colitis typically presents with bloody diarrhea and abdominal discomfort, the severity of which is related to the extent and severity of inflammation. Because ulcerative colitis typically involves the rectum, tenesmus, urgency, rectal pain, and fecal incontinence are common. Patients with ulcerative colitis have distorted and branching colonic crypts on biopsy, but the distribution of inflammation begins in the rectum and progresses up the colon in a continuous and symmetric pattern, without skip areas.
- Colonoscopy results in Crohn disease show patchy distribution of mucosal inflammatory changes with “skip areas” of normal intervening mucosa, and biopsy results for involved mucosa show features of chronicity (distorted and branching colonic crypts).