Differential Diagnosis I:
Crohn’s Disease
Rationale:
Figure 3. Crohn’s Disease (top) McCance & Huether, 2014)
Crohn’s Disease is an idiopathic inflammatory disorder that affects any part of the gastrointestinal tract from the mouth to the anus (McCance & Huether, 2014). Crohn’s Disease is characterized by “skip” lesions and will extend through the layers of the intestinal mucosa, otherwise known as transmural lesions and can affect just one side of the intestinal wall and not the other. Much of the diseased bowel has a characteristic cobblestone appearance from fissured ulcers then edematous tissue. Smoking aggravates the disease course, promotes fistula formation, and contributes to a suboptimal response to medical therapy (Smith & Harris, 2014). Clinical manifestations of Crohn’s Disease include abdominal pain and cramping, diarrhea (>5 per day), passage of blood and mucus, and malabsorption of important electrolytes, nutrients, and vitamins, resulting in anorexia, anemia, and unintentional weight loss.
Our patient presents with signs and symptoms closely match those that one would experience with Crohn’s. Mr. Stein is experiencing several (6-10) episodes of diarrhea per day that contains mucus and blood. Abdominal pain, severe at times. Family history is positive for inflammatory bowel disease in mother. His lab values are concerning for anemia and infection. Further testing, such as computed tomography (CT) of abdomen and pelvis will help make the initial diagnosis, define the extent and location of the disease, and rule out perforation and abscess. A magnetic resonance (MR) enterography can help to pinpoint the location of the diseased bowel (Smith & Harris, 2014). Also, endoscopy and colonoscopy, are useful to confirm or rule out the clinical diagnosis for Crohn’s Disease.
Differential Diagnosis II:
Ulcerative Colitis
Rationale:
Ulcerative Colitis is a chronic inflammatory disease that causes ulceration of the colonic mucosa and extends proximally from the rectum into the colon (McCance & Huether, 2014). Signs and symptoms closely match those of Crohn’s Disease in that there are pe
Figure 4. Acute Ulcerative Colitis (McCance & Huether, 2014)
riods of remission and exacerbation with bloody, purulent, mucoid stools and severe abdominal pain and cramping. The pathophysiology of Ulcerative Colitis affects the mucosa layer only of the colon. It does not have the characteristics of “skip lesions” as in Crohn’s and ulcerations are not transmural. Ulcerative Colitis lesions are continuous in nature and the rectum is almost always involved (McCance & Huether, 2014). Although Ulcerative Colitis is not as common in smokers, this diagnosis is a possibility for our patient and further testing is necessary to rule it out.
We consider the Ulcertaive Colitis diagnosis as a possibility for our patient because the signs and symptoms experienced such as the severe abdominal cramping, bloody diarrhea, and unintentional weight loss are very similar in nature to that of Crohn’s Disease.
Differential Diagnosis III:
Celiac Disease
Rationale:
Figure 5. Gluten-Sensitive Enteropathy (Celiac Disease) (McCance & Huether, 2014)
Celiac Disease, also named celiac sprue or gluten-sensitive enteropathy, is an autoimmune disease of the small intestinal villous epithelium where there is an ingestion of the cereal protein gluten (gliadin) found in wheat, rye, barley, and oats in genetically susceptible individuals (McCance & Huether, 2014). Many individuals have this condition as children; however, it is more commonly diagnosed in adulthood. Pathophysiology is complex but involves both cellular and humoral immunity. It involves damage to the small upper intestinal mucosal cells causing an inflammation process, atrophy, and flattening of the villi. The increased epithelial cell production is not enough to keep up with the destruction, leaving patches of bald mucosa (McCance & Huether, 2014). Individuals suffer with malabsorption, anorexia with weight loss, occult blood and/or anemia, and watery diarrhea.
Mr. Stein expresses signs and symptoms of Celiac disease that relate to Crohn’s Disease and Ulcerative Colitis, such as multiple bowel movements, anemia, anorexia, and unintentional weight loss. Although Celiac Disease is less likely in his case, however, we should rule out this diagnosis in our effort to correctly treat him.