A 24-year-old woman comes to the office due to recurrent bloody diarrhea and right-sided abdominal pain. She has had these symptoms intermittently for several years but has not sought medical attention until now. Colonoscopy shows evidence of inflammation and dysplasia. The patient is started on appropriate medical therapy but her symptoms fail to respond adequately. She subsequently undergoes a colectomy of the involved region; findings are shown in the image. The intestinal wall appears thickened. Which of the following is the most likely diagnosis?

Question

A 24-year-old woman comes to the office due to recurrent bloody diarrhea and right-sided abdominal pain.  She has had these symptoms intermittently for several years but has not sought medical attention until now.  Colonoscopy shows evidence of inflammation and dysplasia.  The patient is started on appropriate medical therapy but her symptoms fail to respond adequately.  She subsequently undergoes a colectomy of the involved region; findings are shown in the image.  The intestinal wall appears thickened.  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

11ec160b_3951_db95_9249_8b23c26ee51a_MD0001_00 Crohn disease (CD) is an inflammatory bowel disease characterized by patchy inflammation that can occur throughout the entire gastrointestinal (GI) tract; patients commonly complain of relapsing and remitting abdominal pain, diarrhea (with or without blood), and weight loss. CD typically involves the ileum; however, up to 20% of patients have only colonic involvement. Unlike ulcerative colitis, which is characterized by continuous inflammation of the colon limited to the mucosa and submucosa, inflammation in CD is transmural (full thickness) and segmental in nature. This leads to recognizable manifestations on gross pathology, including: Skip lesions - sharply delineated ulcerations surrounded by normal bowel Cobblestone appearance - serpiginous (ie, wavy, snakelike) depressed ulcerations that separate elevated islands of healthy tissue (giving the mucosa an appearance of a cobblestone street) Bowel wall thickening - due to inflammation involving all layers of the bowel wall leading to edema, hypertrophy of the muscularis mucosa, and fibrosis Creeping fat - mesenteric fat becomes wrapped around the bowel, possibly in response to intestinal bacteria translocation In addition, the transmural inflammation frequently leads to complications such as abscesses, strictures, and fistulas. (Choice A) Amoebic dysentery caused by Entamoeba histolytica causes hematochezia, abdominal pain, and ulcerations; however, the ulcers are classically flask-shaped and smaller than those seen with inflammatory bowel disease. (Choice B) Collagenous colitis can cause chronic watery diarrhea (>5-10 episodes daily) but is commonly seen in middle-aged women and is not associated with bleeding, ulcerations, inflammation, or abdominal pain. (Choice D) Graft-versus-host disease of the GI tract can cause abdominal pain and ulcerations, but it typically causes severe diarrhea (up to 10 L daily) and occurs as a complication of allogeneic stem cell transplant. (Choice E) Pseudomembranous colitis occurs from Clostridioides difficile infection (CDI). It causes abdominal pain and diarrhea that can result in toxic megacolon. A white/yellow, patchy pseudomembrane, composed of inflammatory cells, fibrin, and cellular debris, is often visualized. In addition, CDI is typically associated with recent antibiotic use. (Choice F) Ulcerative colitis is characterized by contiguous inflammation that extends from the rectum. Ulcerations are shallow and involve only the mucosa and submucosa; pseudopolyps (areas of inflamed mucosa and/or granulation tissue that appear polyp-like due to surrounding ulcerations) are seen; bowel wall thickening is not as prominent as with CD. Educational objective: Crohn disease is an inflammatory bowel disease characterized by patchy inflammation that can occur throughout the entire gastrointestinal tract. Gross pathology demonstrates skip lesions, cobblestoning of the mucosa, bowel wall thickening, and creeping fat.

A 24-Year-Old Woman Comes to the Office Due to Recurrent