Skill Checkup: A 28-Year-Old Man With Diarrhea, Nausea, Vomiting, and Abdominal Cramping

Charles Bernstein, MD


February 01, 2022

This patient was previously diagnosed with Crohn disease, which has progressed to moderate to severe disease. Severity may be based on impact of the disease on the patient, objective measures of inflammatory burden, and disease course. The most common symptom of this condition is chronic diarrhea, with pain in the right lower quadrant of the abdomen that worsens postprandially. Other symptoms include fatigue and weight loss. Factors that influence the course of disease include younger age at onset, as seen in this case, as well as disease activity, distribution, and phenotype.

The prevalence of inflammatory bowel disease is increasing worldwide, with the highest reported prevalence in Europe and North America. Globally, peak onset of Crohn disease is between 15 and 30 years of age, with one quarter of all inflammatory bowel disease cases diagnosed in patients younger than 18 years. Ashkenazi Jews are at higher risk of developing the condition than any other ethnic group. The age of onset shows a unimodal distribution: The first, more predominant wave occurs in adolescence and early adulthood, but the disease can be diagnosed at any age.

Distinguishing ileocolitis associated with Crohn disease from colitis with backwash ileitis is straightforward when granulomas are seen histologically or, when aphthous ulcers, cobblestoning, and skip lesions are seen endoscopically.

The risk for gastrointestinal cancer is significantly elevated in patients with inflammatory bowel disease. Crohn disease may be complicated by small-bowel adenocarcinoma, which is primarily seen in men or patients with excluded bowel loops, as well as at the distal ileum of active disease. Ileal Crohn disease that is refractory to medical therapy should raise suspicion for a small-bowel neoplasm. Ileoscopy with biopsy may help exclude this diagnostic possibility.

Clostridioides difficile infection may occur after colectomy and can cause antibiotic-associated colitis. The condition manifests with low-grade fever, abdominal or pelvic pain, and increased ileostomy output and can be confirmed diagnostically with pseudomembranes and/or toxin-producing organisms on stool studies.


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