Jessica Alper Discussion Differential diagnosis Crohn’s Disease is classified as a type of chronic inflammatory bowel disease (IBD), leading to digestive disorders including inflammation of the digestive system. Some factors associated with it are geographical location, inappropriate diet, genetics, as well as inappropriate immune responses (Seyedian et al., 2019). Crohn’s disease can mimic other types of diseases, which can make it difficult to diagnose. Symptoms associated with this condition include pain, diarrhea, fever and more. It usually affects the mouth, anus, and the entire layers of the intestines.  The first differential diagnosis is Ulcerative Colitis (UC), which is another type of IBD and can also lead to inflammation of the gastrointestinal tract. Symptoms associated with UC include diarrhea, abdominal pain, rectal bleeding, as well as weight loss. Symptoms are typically “limited to the colon and is found mostly in some parts of the large intestine including colon and rectum” (Seyedian et al., 2019).  The second differential diagnosis is celiac disease. Caio et al. (2019) state that this condition is autoimmune, and it is “characterized by a specific serological and histological profile triggered by gluten ingestion in genetically predisposed individuals”. Gluten is described as a protein that is alcohol-soluble and presents in several cereals, such as wheat, rye, barley, spelt and more. Symptoms include diarrhea, fatigue, weight loss, bloating, gas, abdominal pain, nausea, and vomiting.  The third differential diagnosis for this condition is diverticulitis, which is defined as an inflammation of the diverticulum in the colon. It can be either acute or chronic, and it is most specifically described as an “obstruction of the diverticulum sac by fecalith, which by irritation of the mucosa causes low-grade inflammation, congestion and further obstruction” (Rezapour et al., 2017). Multiple factors can contribute to this disease, such as colonic wall structure, colonic motility, genetics, fiber intake, vitamin D levels, obesity, as well as physical activity.  Physical exam findings When examining a patient with Crohn’s disease, it is important to focus on a few different factors, such as temperature, weight, nutritional status, presence or absence of abdominal tenderness or a mass, perianal along with rectal examination findings, additionally to extraintestinal manifestations (Ghazi, 2019). Some findings from the physical assessment can vary from fullness to discrete masses, especially in the right lower quadrant of the abdomen, which typically involves the ileal part of the colon. Other masses may be felt due to the thickened or matted loops of the inflamed bowels.  Upon assessing the perianal area, more information can be provided to increase the suspicion of the inflammatory bowel disease. Skin tags, fistulae, ulcers, abscesses, and scarring may be noted. Additionally, performing a rectal examination can help assess the sphincter ...

1. Jessica Alper Discussion
Differential diagnosis
Crohn’s Disease is classified as a type of chronic inflammatory
bowel disease (IBD), leading to digestive disorders including
inflammation of the digestive system. Some factors associated
with it are geographical location, inappropriate diet, genetics,
as well as inappropriate immune responses (Seyedian et al.,
2019). Crohn’s disease can mimic other types of diseases, which
can make it difficult to diagnose. Symptoms associated with this
condition include pain, diarrhea, fever and more. It usually
affects the mouth, anus, and the entire layers of the intestines.
The first differential diagnosis is Ulcerative Colitis (UC), which
is another type of IBD and can also lead to inflammation of the
gastrointestinal tract. Symptoms associated with UC include
diarrhea, abdominal pain, rectal bleeding, as well as weight
loss. Symptoms are typically “limited to the colon and is found
mostly in some parts of the large intestine including colon and
rectum” (Seyedian et al., 2019).
The second differential diagnosis is celiac disease. Caio et al.
(2019) state that this condition is autoimmune, and it is
“characterized by a specific serological and histological profile
triggered by gluten ingestion in genetically predisposed
individuals”. Gluten is described as a protein that is alcohol-
soluble and presents in several cereals, such as wheat, rye,
barley, spelt and more. Symptoms include diarrhea, fatigue,
weight loss, bloating, gas, abdominal pain, nausea, and
vomiting.
The third differential diagnosis for this condition is
diverticulitis, which is defined as an inflammation of the
diverticulum in the colon. It can be either acute or chronic, and
it is most specifically described as an “obstruction of the
diverticulum sac by fecalith, which by irritation of the mucosa
causes low-grade inflammation, congestion and further
obstruction” (Rezapour et al., 2017). Multiple factors can

2. contribute to this disease, such as colonic wall structure,
colonic motility, genetics, fiber intake, vitamin D levels,
obesity, as well as physical activity.
Physical exam findings
When examining a patient with Crohn’s disease, it is important
to focus on a few different factors, such as temperature, weight,
nutritional status, presence or absence of abdominal tenderness
or a mass, perianal along with rectal examination findings,
additionally to extraintestinal manifestations (Ghazi, 2019).
Some findings from the physical assessment can vary from
fullness to discrete masses, especially in the right lower
quadrant of the abdomen, which typically involves the ileal part
of the colon. Other masses may be felt due to the thickened or
matted loops of the inflamed bowels.
Upon assessing the perianal area, more information can be
provided to increase the suspicion of the inflammatory bowel
disease. Skin tags, fistulae, ulcers, abscesses, and scarring may
be noted. Additionally, performing a rectal examination can
help assess the sphincter tone and gross abnormalities of the
rectal mucosa can be observed. Other extraintestinal
manifestations may be noted with Crohn’s disease, such as the
skin, joints, mouth, eyes, liver, or bile ducts, and especially
arthritis and arthralgia. Lastly, “examination of the skin and
oral mucosa may show mucocutaneous or aphthous ulcers,
erythema nodosum, and pyoderma gangrenosum” (Ghazi, 2019).
Other signs include pallor in anemic patients, jaundice in
patients with liver disease with cholestasis, as well as
episcleritis.
Diagnostic testing
The diagnosis of Crohn’s disease can be made based on the
clinical, laboratory, histologic and radiologic findings. Several
procedures may be performed to confirm the diagnosis.
Performing a colonoscopy is the test of choice in order to assess
the disease activity in patients with this condition. An
alternative option is to perform complementary cross-sectional
imaging to assess the phenotype. An upper gastrointestinal (GI)

3. endoscopy and histologic examination may be recommended
when the colonoscopy is “unable to definitely diagnose Crohn’s
disease or in the presence or upper GI symptoms” (Ghazi,
2019). Ordering plain radiography or CT scan of the abdomen
may also be used to assess for any bowel obstructions. They can
also be used to assess the pelvis for any type of intra-abdominal
abscesses. CT enterography or MRI can now replace the small
bowel follow-through studies, as they help better differentiate
between inflammation and fibrosis. Lastly, an MRI of the pelvis
or endoscopic ultrasounds can help assess for perianal fistulae
and may also help detect the presence of pelvic or perianal
abscesses.
Additionally to diagnostic tests, some laboratory values might
help narrow down the diagnosis of Crohn’s disease. CRP and
ESR can be associated with complications of the condition. The
full diagnosis is made by endoscopic visualization and biopsy,
especially a “colonoscopy with intubation of the terminal ileum
that is used to evaluate the extend of the disease, to demonstrate
strictures and fistulae, and to obtain biopsy samples to help
differentiate the process from other inflammatory, infectious, or
acute conditions” (Ghazi, 2019).
Treatment Plan
It is important to note that the treatment of Crohn’s disease is
based on the disease site, the pattern, the activity as well as the
severity. One specific goal of treatment includes achieving “the
best possible clinical, laboratory, and histologic control of the
inflammation disease with the least adverse effects from
medication” (Ghazi, 2019). Another goal is to allow the patient
to properly function on a daily basis, as well as promoting
growth with adequate nutrition in children.
Veauthier and Hornecker (2018) state that the management of
Crohn’s disease aims at first treating the inflammatory process
along with the associated complications, while achieving and
maintaining remission. Antibiotics should be limited to treating
complications, such as abscesses and fistulas. Some medication
treatments include prescribing corticosteroids,

4. immunomodulators as well as biologics. Corticosteroids
typically includes tapering courses of prednisone, starting with
40 to 60mg based on the severity of the symptoms, and
decreasing by 5 mg until 20mg is reached, then decreasing by
2.5 to 5mg until discontinuation is achieved. As far as
immunomodulators, thiopurines and methotrexate can be used to
induce remission. Monoclonal antibodies, such as anti-TNF
agents, anti-integrin agents and anti-interleukin antibody
therapy may help induce remission and should be continued for
maintenance. Depending on the severity of the symptoms and
the disease process, early resection may be an option if the
disease is limited to the ileocecal region (Veauthier &
Hornecker, 2018).
References
Caio, G., Volta, U., Sapone, A., Leffler, D. A., De Giorgio, R.,
Catassi, C., & Fasano, A. (2019). Celiac disease: A
comprehensive current review. BMC medicine, 17(1), 142.
https://doi.org/10.1186/s12916-019-1380-z
Ghazi, L. J. (2019). Crohns disease clinical presentation.
Medscape.
https://emedicine.medscape.com/article/172940-
clinical#b3
Rezapour, M., Ali, S., & Stollman, N. (2018). Diverticular
disease: An update on pathogenesis and management. Gut and
liver, 12(2), 125–132.
https://doi.org/10.5009/gnl16552
Seyedian, S. S., Nokhostin, F., & Malamir, M. D. (2019). A
review of the diagnosis, prevention, and treatment methods of
inflammatory bowel disease.
Journal of medicine and life,
12(2), 113–122.
https://doi.org/10.25122/jml-2018-0075
Veauthier, B., & Hornecker, J. R. (2018). Crohn's disease:
Diagnosis and management. American Family Physician,
98(11), 661-669.

5. An 18-year-old white female presents to your clinic today with
a 2-week history of intermittent abdominal pain. She also is
positive for periodic cramping and diarrhea as well as low grade
fever. She also notes reduced appetite. She notes that She
admits smoking ½ PPD for the last 2 years. Denies any illegal
drug or alcohol use. Does note a positive history of Crohn's
Disease. Based on the information provided answer the
following questions:
1. What are the top 3 differentials you would consider with the
presumptive final diagnosis listed first?
2. What focused physical exam findings would be beneficial to
know?
3. What diagnostic testing needs completed if any to confirm
diagnosis?
4. Using evidence-based treatment guidelines note a treatment
plan.