A 29-year-old woman comes to the office to establish care. The patient feels well overall but has had 4-5 loose bowel movements a day with mild, cramping abdominal pain. She has no weight loss, bloody stools, vomiting, rashes, or joint pain. Medical history is significant for long-standing Crohn disease that required an ileocolectomy 3 years ago. The patient has been taking adalimumab and azathioprine since the surgery. In addition to Crohn disease, she has type 2 diabetes, morbid obesity, and generalized anxiety disorder. The patient frequently consumes fast food and rarely eats fruits, vegetables, or whole wheat bread. She has smoked both cigarettes and marijuana for the past 15 years. Temperature is 37.5 C (99.5 F), blood pressure is 132/89, pulse is 80/min, and respirations are 12/min. BMI is 41 kg/m². Oropharyngeal examination reveals moist mucosal membranes and no mouth ulcers. Heart and lung sounds are unremarkable. The abdomen has a well-healed laparoscopic scar but is otherwise nontender and nondistended. Which of the following is most strongly associated with progression of this patient's Crohn disease?

Question

Quizplus · Accepted Answer

This patient has severe Crohn disease, evidenced by the prior need for surgery and her young age at the time of diagnosis. Such patients are at high risk for disease recurrence; >50% require repeat surgery within 10 years if the disease is not properly controlled. Most patients with severe Crohn disease are medically managed with biologic therapy (eg, tumor necrosis factor-alpha inhibitors) and/or immunomodulators (eg, azathioprine, 6-mercaptopurine) and require close endoscopic surveillance to ensure sustained remission. This patient should be advised to stop smoking because it is the only major modifiable risk factor that affects the severity and progression of Crohn disease. Smoking is strongly associated with an increased need for hospitalizations and intestinal surgery as well as failure of biologic therapy. Other risk factors for severe disease include young age (<30 years) at diagnosis, extensive anatomic involvement, perianal disease, deep ulcerations, strictures, fistulization, and prior intestinal surgery. (Choices B and E) Both obesity and diabetes mellitus have been associated with colon cancer but neither increases the risk for complications related to Crohn disease. Obesity is also considered a risk factor for diverticulosis, but diabetes mellitus does not share this association. (Choice C) Patients with Crohn disease, as well as irritable bowel syndrome, are at increased risk for mood disorders, including generalized anxiety disorder; however, concurrent mood disorders do not influence the progression or severity of Crohn disease. (Choice D) The effect of medical marijuana on the progression of Crohn disease is unclear; therefore, it is not recommended for these patients. Furthermore, marijuana is a major risk factor for cyclic vomiting syndrome, and in the absence of a known medical benefit, cessation should be recommended. Educational objective: Patients with severe Crohn disease, especially those who have required intestinal surgery in the past, are at high risk for future complications and often need aggressive management with biologic and/or immunomodulator therapy. Smoking is strongly associated with increased severity and progression of Crohn disease and should be avoided in these patients. References: ACG clinical guideline: management of Crohn's disease in adults. (http://www.ncbi.nlm.nih.gov/pubmed/29610508) Smoking prevalence and its influence on disease course and surgery in Crohn's disease and ulcerative colitis. (http://www.ncbi.nlm.nih.gov/pubmed/25968332)

A 29-Year-Old Woman Comes to the Office to Establish Care