A 28-year-old man with vague abdominal pain, low-grade fever, and diarrhea is treated with antibiotics without significant improvement in his symptoms. Several weeks after symptom onset, the patient develops a skin lesion over the abdomen. His temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, and pulse is 88/min. On physical examination, the abdomen is mildly distended and tender to palpation. Bowel contents appear to be draining to the surface of the skin in the right lower abdominal quadrant. This patient most likely suffers from which of the following conditions?

Question

A 28-year-old man with vague abdominal pain, low-grade fever, and diarrhea is treated with antibiotics without significant improvement in his symptoms.  Several weeks after symptom onset, the patient develops a skin lesion over the abdomen.  His temperature is 37.8 C (100 F), blood pressure is 120/70 mm Hg, and pulse is 88/min.  On physical examination, the abdomen is mildly distended and tender to palpation.  Bowel contents appear to be draining to the surface of the skin in the right lower abdominal quadrant.  This patient most likely suffers from which of the following conditions?

Quizplus · Accepted Answer

11ec160b_3950_54ef_9249_47685f79f556_MD0001_00 Crohn disease and ulcerative colitis are collectively referred to as inflammatory bowel disease. They may have similar clinical manifestations, but they also have key distinguishing features (Table). Crohn disease typically presents with prolonged diarrhea and abdominal pain. Diarrhea can be bloody if the colon is involved. Constitutional symptoms (eg, low-grade fever, fatigue), malabsorption, and weight loss are also common. Transmural inflammation of the bowel wall may result in the formation of fistulas and fibrotic strictures, causing bowel obstruction. Fistulas can form between 2 adjacent loops of bowel (enteroenteric fistula), between the bowel and another organ (eg, bladder, vagina), or between the bowel and skin of the abdominal wall (enterocutaneous fistula). Perianal fistulas and abscesses are also often seen. Ulcerative colitis typically presents with bloody diarrhea associated with abdominal pain and tenesmus. Fistula formation does not usually occur as inflammation is confined to the mucosa and submucosa (Choice E). (Choice A) Right lower quadrant abdominal pain, fever, nausea, and vomiting are classic symptoms of acute appendicitis. If untreated, appendicitis may progress to peritonitis or abscess formation, but fistula formation is not common. (Choice C) Mesenteric adenitis most often occurs in children age 5-14. Many cases are thought to be associated with Yersinia enterocolitica infection. Clinical manifestations may include fever, right lower quadrant abdominal pain, and nausea/vomiting, but fistulas are not characteristic. (Choice D) Pseudomembranous colitis is typically caused by Clostridium difficile infection and presents with diarrhea, abdominal pain, and fever in a patient who has recently been hospitalized or treated with antibiotics. Fistulas are not typically seen. Educational objective: Crohn disease typically presents with prolonged diarrhea and abdominal pain. Constitutional symptoms (eg, low-grade fever, fatigue), malabsorption, and weight loss are also common. Transmural inflammation of the bowel wall may result in the formation of fistulas (eg, enteroenteric, enterocutaneous), abscesses, and fibrotic strictures. __________ References: Diagnosis and management of Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/22230271) Natural history and long-term clinical course of Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/24415855)

A 28-Year-Old Man with Vague Abdominal Pain, Low-Grade Fever, and Diarrhea