MORNING REPORT

August 28, 2013 Jessica Miller, MD, PGY2

HPI
15 year old girl with history of abdominal pain for 3 months, acutely worse in the past 5 days
Over the past 3 months: Dull backdrop of achy pain throughout abdomen (points to periumbilical area) Episodes of increased sharp, stabbing pain often lasting for 1-2 days, then subsiding Nausea, occasional vomiting (non-bloody, non-bilious) Intermittent diarrhea/ constipation Slightly decreased appetite, no weight loss Seen at multiple Urgent Care clinics- no imaging or labs done

HPI
In the past 5 days Pain localized to the RLQ Continues to vary in intensity, sometimes achy, sometimes more sharp Non-radiating Increased nausea Increased diarrhea Subjective fever at home, temperature not actually measured

REVIEW OF SYSTEMS
GEN: no weight loss, subjective fever

HEENT: cough, rhinorrhea about 1 week prior to

presentation CV: no palpitations, no dizziness PULM: no shortness of breath, difficulty breathing ABD: + nausea, + vomiting, + intermittent, sharp abdominal pain, + diarrhea/ constipation GU: no pain with urination, no change in vaginal discharge NEURO: no headaches, no vision changes EXT: several red bumps on R-arm she thinks are insect bites

PAST MEDICAL HISTORY

Born by C/S due to repeat C/S, no complications during

delivery or after birth Exercise-induced asthma controlled with albuterol Secondary Amenorrhea- had one menses at age 14, none since No previous hospitalizations No previous surgeries

FAMILY AND SOCIAL HISTORY

FAMILY HISTORY Mother and older sister with irritable bowel disease Father with appendicitis DM2 in MGM and PGF Thyroid disease in PGF SOCIAL HISTORY Parents divorced, lives primarily with mother Has an older brother and sister Entering 10th grade, does well in school, enjoys reading Not sexually active, no current boyfriend/girlfriend Denies any tobacco, drug or alcohol use

PHYSICAL EXAM
T 37.6 HR 130 BP 121/77 WT: 38 KG (1%) HT: 147 CM (1%) GEN: pleasant, appropriate, lying in bed HEENT: clear conjunctiva without injection or icterus, EOMI, no lymphadenopathy, tachy mucus membranes PULM: no increased work of breathing, CTAB CARDIAC: tachycardia, no murmurs, peripheral pulses palpable in upper and lower extremities, cap refill 2-3 sec ABD: distended, tender in RUQ and RLQ, + rebound tenderness, + bowel sounds, no hepatomegaly of splenomegaly GU: tanner 4 external genitalia, anus without fissures/inflammation, pelvic ultrasound demonstrated normal left ovary, right ovary not visualized EXT: no rashes, warm, well perfused

DIFFERENTIAL DIAGNOSIS
15 year old girl with intermittent abdominal pain for the past 3 months, acutely worse, localized to the RLQ over the past 5 days

DIFFERENTIAL DIAGNOSIS
GI: Appendicitis Cholecystitis Constipation Irritable Bowel Disease Inflammatory Bowel Disease Functional Abdominal Pain Gastroenteritis Incarcerated inguinal hernia Peptic Ulcer Disease Mesenteric Lymphadenitis Pancreatitis Celiac disease GU: Ovarian torsion Ovarian cyst Endometriosis Ectopic pregnancy UTI Urolithiasis Pelvic Inflammatory Disease ID: Tuberculosis Viral/Bacterial gastroenteritis Abdominal abscess Hepatitis HEME/ONC: Burkitt Lymphoma Ovarian tumor Sarcoma Hepatocellular carcinoma Sickle Cell

TOX: Lead Poisoning

NEURO: Abdominal Migraine

CV: Aortic dissection Myocarditis Pericarditis

INITIAL WORKUP: labs

CBC: WBC- 11.6 (0% B, 82% N, 8.7% L, 7% M, 1% E),

Hgb-14.4 Hct-42.7 Plt- 381

CMP: Na 143, K 4.3, Cl 100, CO2 28, Glucose 94, BUN 10, Cr 0.61,

Ca 10.0, Prot 8.1, Alb 4.3, TB 0.6, Alk Phos 162, ALT 30 AST 28 GGT -40 Lipase- 57 UA: 1.020, - glucose, trace ketones, - nitrites, trace protein, -LE, 1 WBC, 0 RBC, 1 Epi, BHCG: negative ESR: 21 CRP: 2.8 Stool Guiac: negative EHEC: negative C. Diff: negative

INITIAL WORKUP: imaging

Pelvic US: left ovary well visualized, no ovarian torsion,

right ovary not well visualized due to overlying loop of bowel

RLQ US: acute, enlarged blind ending loop of bowel in

RLQ , small amount of free fluid IMRESSION: Acute appendicitis

To the operating room

OPERATIVE FINDINGS:
Appendix normal in appearance BUT creeping fat surrounding ileum

ILEITIS: what can cause it?

ILEITIS: what can cause it?

Autoimmune Chrohns disease SLE Polyarteritis nodosa HSP Infectious Mycobacterium tuberculosis Yersinia Salmonella CMV Histoplasmosis Medications NSAIDS OCPs, diuretics, antihypertensive Neoplasms Cecal/small bowel adenocarcinoma Lymphoma Metastatic cancer Eosinophilic ileitis

FURTHER WORKUP
EGD: Esophagus, stomach, duodenum normal in appearance Colonoscopy: Colon normal in appearance Ileum scarred off, unable to advance scope through the ICV Biopsies taken of the ileum MRE: Significant bowel wall thickening extending from the ileocecal bowel into the distal ileum, approximately 15 cm Signicicant mucosal enhancement in the distal ileum with contrast administration Mild enhancement in the adjacent colon

FURTHER WORKUP
PATHOLOGY Duodenem: Intact villous architecture with increased intraepithelial lymphocytes Stomach: Chronic gastritis with rare epithelial granuloma Esophagus: mild focal prominence of intraepithelial lymphocytes Terminal ileum: active ileitis Ascending colon: no diagnostic abnormality Transverse colon: granulomatous colitis Sigmoid colon and rectum: no diagnostic abnormality

CHROHNS DISEASE: incidence

5-10/ 100,000 per year

20-25% of these cases are diagnosed in children < 18

years Seems to be increasing Ethnic trends:

Higher incidence reported for Caucasian than African American/

Hispanic ethnicities May be due in part to sampling bias

Geographic trend: More common in North America/ UK/ Scandinavia Less common in Southern Europe, Asia, Africa

CHROHNS DISEASE: etiology

ETIOLOGY Exact etiology unknown Genetic predisposition + environmental trigger
10-25 % have a first degree relative with IBD

Possible triggers:
environmental antigen
intestinal bacteria/ antigen

CHROHNS DISEASE: presentation

Abdominal pain (95%)

Weight loss (80%)

Diarrhea (77%) Hematochezia (60%) Growth failure (30%) Extraintestinal (30%)

(Gryboski 1994)

ABDOMINAL SYMPTOMS
from the mouth to the anus
Diarrhea Blood in stool Tenesmus Vague abdominal pain Right lower quadrant pain

GROWTH FAILURE
Definition: Growth velocity of < 5 cm/year Decrease in growth velocity > 2 cm as compared to the previous year In one study, occurred in 50% of patients with Chrohns disease In another study, occurred in 30% of Chrohns disease, 10 -15%

of Ulcerative Colitis Often precedes abdominal symptoms Cause:

Anorexia:
IL-1,TNF-alpha Pain with eating

Malabsorbtion Decreased growth hormone Impaired response to growth hormone

PUBERTAL DELAY
More common in boys than in girls

In one study, menarche delayed until after age 16 in of

girls (Ferguson 1994) Mechanism

Likely similar mechanisms leading to delays in linear growth

MICRONUTRIENT DEFICIENCIES
Location of active disease determines risk Fat soluble vitamins (decreased bile acid resorption in terminal ileum fat malabsorbtion)
Vitamin D Vitamin A

Vitamin E
Vitamin K

Zinc (increased loss with fistulas, diarrhea) Iron (chronic blood loss, suppression of erythropoietin) Vitamin B12 (more common with ileal involvement) Calcium (loss in lumen with fat, Vitamin D deficiency)

ORAL LESIONS: what to look for

MUCOGINIGIVITIS= inflammation at line of oral mucosa

and gingival tissue

MUCOSAL TAGS DEEP ULCERATIONS

COBBLESTONING
LIP SWELLING

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PERIANAL DISEASE
Affects 35-45% of patients with Chrohns at some point

More common in patients < 40 years

More common if colonic/ rectal involvement than with

small bowel/ ileal involvement Manifestations:

Anal fissures (20%) Anal fistula (20-30%) Anal skin tags Hemorrhoids Over time Anal stenosis

EXTRAINTESTINAL
Incidence10-30% at initial presentation, 30% within the

first few years of diagnosis

Erythema nodosum (CD> UC) Pyoderma gangrenosum (UC > CD) Episcleritis/scleritis

Arthritis
Asymmetric Non-erosive Large joints

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BACK TO OUR PATIENT:

What about her presentation pointed to Chrohns? Amenorrhea Growth Chronicity of symptoms

Her initial treatment: Started on Remicade Sent home on course of Budesonide

RESOURCES
Chrohns disease in Children Gryboski. Pediatrics in Review.

1981; 2: 239. Chrohns disease in children 10 years old and younger: comparison with ulcerative colitis. Gryboski, JD> Journal of Pediatric Gastroenterology and Nutrition. February 1994, 18 (2): 174-82. Ileitis: When it is not Chrohns Disease. Steven Di Lauro, Nancy Crum-Cianflone. Current Gastroenterology. August 2010. 12(4): 249-258. Impact of Inflammatory Bowel Disease on Pubertal growth. Mason, Russell, Bishop, McGorgan. Horm. Res. Paediatrics. 2011; 76 95) 293-299. Juvenile onset inflammatory bowel disease: height and body mass index in adult life. Ferguson, Sedgwick. British Medical Journal 1994; 308, 1259-1263.