Case 4

A 48-year-old man with ileal Crohn’s disease presents for a second opinion on management of Crohn’s disease. He was diagnosed 6 months ago after presenting with diarrhea, abdominal pain, and weight loss. Colonoscopy at that time showed superficial ulcers in the terminal ileum, with biopsies showing chronic active ileitis consistent with Crohns disease. MR enterography showed ileal wall thickening and enhancement of a 20 cm segment of terminal ileum, with no additional diseased segments or signs of intra-abdominal abscess. He was initially treated with a prednisone taper and azathioprine; he finished taking prednisone about 3 months ago and is now on azathioprine monotherapy. He continues to complain of diarrhea and right lower quadrant abdominal pain, which never resolved even while on prednisone. He currently reports 6 loose, non-bloody stools per day, with an occasional nocturnal bowel movement. He endorses postprandial bloating sensation, particularly after eating certain vegetables, but denies any history of bowel obstruction. He also reports fatigue but denies any extraintestinal manifestations of Crohn’s disease. His weight is now stable.

Notable Physical Exam Findings:

Vitals: Within normal limits

General: Thin, no acute distress

Abdomen: Soft, mild tenderness to palpation in the right lower quadrant, no rebound or guarding, non-distended, normal bowel sounds

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