Crohn’s Disease

Patient Presentation:
L.Y., a 39 year old male, presents to the ER with c/o severe, diffuse, intermittent abdominal pain for several months, worsening over the past week and now unbearable. The patient reports that he previously made an appointment with a gastroenterologist for the following week, but was now unable to tolerate the pain any longer.  The patient rates the pain as a 10/10, sharp and cramping in nature. The patient reports being in good health with no past medical history and no other complaints. The patient denies other GI symptoms such as anorexia, nausea, vomiting, diarrhea, and constipation.  Initial Vital Signs: BP 110/70, HR 74, RR 16, O2 Sat 100% on RA, Temp. 98.4.

Differential Diagnosis:
Gastritis, appendicitis, pancreatitis, IBD, Infectious Colitis, IBS, Bowel Obstruction, diverticulitis

Diagnosis:
Upon arrival to the ER, labs were obtained (CBC, CMP, amylase, lipase, ESR, and UA), an 18 gauge IV was placed, and a STAT CT scan of the abdomen/pelvis with PO & IV contrast was ordered.  The results of the patient’s UA, BMP, amylase, and lipase were all WNL.  Abnormal lab values included: an elevated WBC count (14.7), an elevated platelet count (618), and an elevated ESR rate (64).

Treatment:
After the IV was started, a 1L NS bolus was given.  The patient was medicated with 4mg Zofran® IV and 1 mg Dilaudid® IV.  The patient was given the PO CT contrast to drink.  Immediately after administration of IV Dilaudid®, the patient rated his pain as 0/10.  The patient was taken to CT scan approximately 1.5 hrs s/p finishing the PO contrast.  The results of the CT scan showed considerable wall thickening of the distal and terminal ileum, representative of infectious ileitis or Crohn’s disease.  No other impressions were noted on the radiology report.  About 3 hours after the administration of the 1st dose of Dilaudid®, the patient’s pain returned to a 7/10 and the patient was again medicated with 4 mg IV Zofran® and 1 mg IV Dilaudid®.  The patient was then given 400 mg IVPB Cipro® and 500 mg IVPB Flagyl® and an additional 1L NS bolus.  The patient was then discharged to home with prescriptions for Vicodin®, Zofran®, Phenergan®, Cipro®, and Flagyl®.  The patient was given a copy of his lab results, his radiology report, and a DVD of his CT scan and instructed to follow-up with a gastroenterologist as scheduled.

Outcome:
After discharge, the patient went for the scheduled GI follow-up and underwent a colonoscopy.  The results of the colonoscopy showed 15-20 cm of ileitis with mucosal thickening and ulcers; the rest of the colonoscopy was unremarkable.  The patient was diagnosed by the gastroenterologist as having probable Crohn’s Disease, awaiting the official biopsy results and surgical report.  The patient was instructed to follow up again in 2 weeks and in the meantime to continue the antibiotic regimen of Cipro® and Flagyl® and to take the Vicodin®, Zofran®, and Phenergan® as needed.  At the follow up appointment, the patient was diagnosed with Crohn’s Disease, based on the biopsy results and official report from the colonoscopy.  After the 2 week antibiotic regimen, the patient remained mostly pain-free with intermittent episodes of moderate to severe pain.  The patient was then started on a drug regimen of anti-inflammatory (Asacol®) and immunosuppressant (azathioprine) medications. The patient’s current prognosis is good with continued drug therapy, lab work and physical exams every month, and a repeat colonoscopy every year.