Differential Diagnosis I
Ulcerative Colitis
Rationale:
Ulcerative Colitis (UC) is an inflammatory disease that causes ulcerations to the mucosa of the colon, most commonly in the rectum and sigmoid colon. Ulcers tend to appear in individuals between 20-40 years old. The lesions present in the rectum and can extend into the colon, although transmural inflammation and skip lesions are absent. With chronic inflammation, polyps can appear in the colon. Clinical manifestations can include watery diarrhea, abdominal pain, rectal bleeding, fever, increased heart rate, weight loss, mouth ulcers, and anemia. Patient reports of abdominal pain, fatigue, weight loss, and reoccurring mouth sores, as well as being at an age that is commonly susceptible to this disease and having a tender abdomen upon palpation and low-grade temperature upon assessment provide rationale for this diagnosis. After initial testing, low albumin, hemoglobin, and hematocrit levels in the blood along with a positive stool occult blood test provide further rationale for a diagnosis of ulcerative colitis (McCance & Huether, 2019).
Rule Out Diagnosis:
Clinical manifestations of UC closely resemble Crohn disease and require further evaluation and testing to distinguish between the two disorders. In UC, the ulcerations tend to be localized to the sigmoid colon (from rectum and into the large bowel). The patient’s colonoscopy revealed inflammation and strictures in the ascending and transverse colon, as well as the terminal ileum. These sites are the most common affected in Crohn disease. It is also known that UC is less common in individuals who smoke, while Crohn disease is further exacerbated by smoking. The patient’s individualized colonoscopy findings and history of smoking, along with familiar history of Crohn’s and noted recurrent mouth ulcers, help to eliminate Ulcerative Colitis as a possible diagnosis (McCance & Huether, 2019).
https://www.crohnscolitisfoundation.org/what-is-ulcerative-colitis/overview
Differential Diagnosis II
Irritable Bowel Syndrome
Rationale:
Irritable bowel syndrome (IBS) is a disease of the brain and gut, which is characterized by altered bowel functions and abdominal pain. Risk factors include dysfunction of the brain-gut axis (neuroendocrine cells in the gut and dorsal root ganglion neurons), intestinal infections, food allergies or intolerance, and psychosocial factors (smoking, chronic emotional stress, and trauma or abuse), along with having a high prevalence in young to middle aged women. The patient presents with several of the symptoms associated with IBS, such as abdominal pain, 15 pound weight loss, and low-grade fever upon assessment. Due to the patient’s history of lactose intolerance and knowledge that the disease more commonly affects young to middle age women, further testing is warranted. After initial testing, anemia and gastrointestinal bleeding, evidenced by low hemoglobin and hematocrit levels in the blood and a positive stool occult test, provides further rationale for a diagnosis of Irritable Bowel Syndrome (McCance & Huether, 2019).
Rule Out Diagnosis:
Although the patient presents with abdominal pain, the pain present with IBS is typically characterized by being localized in the lower abdomen and associated with bloating. The patient reports mild upper abdominal pain and does not disclose bloating. The criteria for diagnosis of IBS (Rome IV Criteria) include recurrent abdominal pain (for three months or longer), along with the presence of two or more of the following symptoms: incomplete fecal evacuation, change in frequency of stool, and or change in appearance of stool. The patient being seen does not disclose any changes in bowel function or issues with defecation; therefor only the criteria of having abdominal pain is met and does not satisfy the requirements to diagnosis this patient with IBS. The patient’s history of being lactose intolerant may have similar symptoms that resemble those of IBS (McCance & Huether, 2019).
https://www.medscape.org/viewarticle/872892_transcript_2
Differential Diagnosis III
Diverticular Disease of the Colon
Rationale:
Diverticular disease is inflammation of the gastrointestinal tract due to pouches in the mucosa throughout the colon. Risk factors include smoking, lack of physical exercise, poor diet (low in fiber), older age, and genetic precursors. Diverticula (mucosal pouches) can develop anywhere in the GI tract, although most common in the left and right colon. Due to the development of the diverticula, the walls of the colon thicken and have the potential for herniation. The patient presents with abdominal pain, a key indicator in diverticular disease caused by constriction of the thickened wall of the colon, and a low-grade fever on assessment. Patient’s history of smoking and familiar history of Crohn disease also provide further rationale for this differential diagnosis (McCance & Huether, 2019).
Ruling Out Diagnosis:
Although patient presents with abdominal pain, the pain typically present with diverticular disease is a cramping pain in the lower abdomen. The patient presents with moderate upper abdominal pain. Usually, symptoms of diverticular disease are absent. However, accompanying clinical manifestations include diarrhea or constipation, abdominal distention, and leukocytosis (increased WBC count). The patient did not disclose having either diarrhea or constipation and no increase in WBC count was noted on CBC. The patient did report a 15 pound weight loss, but did not specify any dietary changes (possible low fiber intake) that could increase risk. Colonoscopy is the diagnostic tool of choice for visualization of the diverticula. However, the patient’s colonoscopy showed inflammation throughout the bowel, with strictures noted in the transverse colon. These clinical findings, along with no diverticula noted from the colonoscopy, are evidence that Diverticular Disease can be ruled out as a possible diagnosis (McCance & Huether, 2019).
