A 34-year-old man comes to the office due to foul-smelling anal discharge and perianal discomfort for the past several weeks. The patient has a history of recurrent anal fissures and takes a fiber supplement, stool softeners, and a topical analgesic. He also has occasional canker sores and recurrent abdominal pain and diarrhea, which he attributes to the use of laxatives. The patient smokes a pack of cigarettes daily but does not use alcohol or illicit drugs. He has not traveled since a trip to South America a year ago. Temperature is 38 C (100.4 F), blood pressure is 120/76 mm Hg, and pulse is 86/min. Tenderness is present in the right lower quadrant on deep palpation. Perianal examination shows a large posterior skin tag. A fistula anterolateral to the anus is draining whitish material. Further evaluation of this patient is most likely to reveal which of the following?

Question

A 34-year-old man comes to the office due to foul-smelling anal discharge and perianal discomfort for the past several weeks.  The patient has a history of recurrent anal fissures and takes a fiber supplement, stool softeners, and a topical analgesic.  He also has occasional canker sores and recurrent abdominal pain and diarrhea, which he attributes to the use of laxatives.  The patient smokes a pack of cigarettes daily but does not use alcohol or illicit drugs.  He has not traveled since a trip to South America a year ago.  Temperature is 38 C (100.4 F), blood pressure is 120/76 mm Hg, and pulse is 86/min.  Tenderness is present in the right lower quadrant on deep palpation.  Perianal examination shows a large posterior skin tag.  A fistula anterolateral to the anus is draining whitish material.  Further evaluation of this patient is most likely to reveal which of the following?

Quizplus · Accepted Answer

11ec25c8_d3f5_53cb_bc81_eb77c04acb50_MD0003_00 This patient most likely has Crohn disease (CD). CD can involve any component of the gastrointestinal tract from the mouth to the anus and characteristically has skip areas of involvement. Anal fissures are seen in approximately 20% of patients. Aphthous ulcers (ie, canker sores) are an occasional component of the disease but are fairly nonspecific by themselves. Skin tags and fistulas are common perianal manifestations. Other gastrointestinal symptoms include chronic diarrhea and abdominal pain. Extraintestinal manifestations include arthritis, skin lesions, and lung disease. CD commonly presents in patients age 15-40, and there appears to be a slight female predominance. Smoking is a risk factor. Diagnosis can be confirmed with endoscopy or other imaging studies that demonstrate consistent findings (eg, strictures). Biopsy typically reveals focal ulcerations with transmural inflammation. Granulomas are also common. Treatment involves 5-aminosalicylic acid drugs for patients without systemic symptoms and corticosteroids or biologic agents (eg, infliximab) for patients with more severe disease. (Choice A) Intestinal amebiasis due to Entamoeba histolytica can also cause abdominal pain with chronic diarrhea and, rarely, perianal disease; however, stools are most commonly bloody and E histolytica would not explain this patient's oral ulcers. (Choice B) Ulcerative colitis is associated with diffuse colitis with no skip lesions and presents with colicky abdominal pain and inflammatory diarrhea (eg, blood, mucus). However, gastrointestinal involvement is limited to the colon, and both oral and perianal disease would be unusual. (Choice C) Tuberculous enteritis should be included in the differential of CD as it may present similarly with abdominal pain, diarrhea, strictures, and fistula. However, patients classically have fever, night sweats, and weight loss, and oral ulcers would be unusual. (Choice D) Vasculitides such as polyarteritis nodosa can present with recurrent abdominal pain and diarrhea, but the abdominal pain is frequently postprandial as a result of chronic mesenteric ischemia. Patients also commonly have multiple other manifestations, including skin (eg, erythema nodosum), renal, and neurologic disease (eg, mononeuropathy multiplex). Fistulas are not a common complication. Educational objective: Crohn disease can involve any component of the gastrointestinal tract from the mouth to the anus, such as aphthous ulcers and perianal skin tags and fistulas. Biopsy typically reveals focal ulcerations with transmural inflammation. References: Diagnosis and management of Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/22230271) Treatment of peri-anal fistula in Crohn's disease. (http://www.ncbi.nlm.nih.gov/pubmed/25309057)

A 34-Year-Old Man Comes to the Office Due to Foul-Smelling