Crohn's Disease Flare with Small Bowel Stenosis in Young Adult Patient

Case at a Glance

A 27-year-old female with a history of Crohn's disease presented to the emergency department with severe abdominal pain and bowel obstruction symptoms. CT imaging revealed small bowel stenosis with dilation, confirming disease recurrence after years of relative remission.

Patient's Story

The patient, a graduate student studying abroad, experienced months of progressive abdominal pain that was initially attributed to anxiety and irritable bowel syndrome by healthcare providers. She presented to the emergency department with 10/10 abdominal pain and significant bowel distress. The patient has a family history of Crohn's disease and was initially diagnosed at age 17 with findings of microgranuloma and cryptitis in the terminal ileum, though previous imaging had been unremarkable. She expressed significant concern about her prognosis, treatment accessibility, and impact on her academic and personal life.

Initial Assessment

Physical examination revealed a patient in severe distress with abdominal pain. Vital signs were stable following initial treatment. Laboratory studies showed elevated neutrophils at 89.8% with lymphocytes at 6.1%, suggesting an inflammatory process. The patient weighed approximately 45kg with a height of 1.6m, indicating possible weight loss from her condition.

The Diagnostic Journey

CT scan of the abdomen and pelvis revealed: small bowel stenosis, small bowel dilation, loops of small intestine with liquid content in the pelvis, and spiral appearance of adjacent mesenteric vessels consistent with inflammatory bowel disease. Incidental findings included a 25mm hypodense cystic formation in the left adnexal area and an accessory spleen. MRI was ordered for disease staging and further characterization of the inflammatory changes.

Final Diagnosis

Crohn's disease flare with small bowel stenosis and obstruction. Secondary findings include left ovarian cyst and accessory spleen (anatomical variant).

Treatment Plan

Emergency management included IV hydration with normal saline, anti-spasmodic therapy (butylscopolamine 20mg), corticosteroids (hydrocortisone 100mg and methylprednisolone 125mg), antiemetic therapy (ondansetron 8mg), proton pump inhibitor (pantoprazole 40mg), pain management (tramadol 100mg), and anxiolytic support (diazepam 5mg). The patient responded well to this regimen. Outpatient management plan includes budesonide therapy with consideration for biologic agents if corticosteroid therapy proves insufficient.

Outcome and Follow-up

The patient's acute symptoms resolved with emergency treatment. She was scheduled for urgent MRI for disease staging and referred back to her home gastroenterologist for ongoing management. The treatment team discussed the potential need for biologic therapy and addressed the patient's concerns about medication side effects, given her previous experience with budesonide-induced mood changes. Flight safety clearance was to be determined pending MRI results and clinical stability.