Medic_90x

2+ Year Member
Apr 7, 2017
34
5
Status
Medical Student
20 year old female presents to the ER with abdominal pain. Afebrile and normal vitals.

Pregnancy test negative. Labs normal. Ultrasound normal, no stones.
CT (resident read) shows nonspecific inflammatory findings. Patient is sent home and her chlamydia test later returns positive. Attending CT read finds significant inflammatory findings in the mesentery and omentum, and she is told to return to the ER. Negative GU physical exam. But she is treated for PID with doxy and ceftriaxone. Later she presents to the clinic still complaining of abdominal pain and she stopped the doxy early on due to nausea. Presumably she still has PID, is treated with azithromycin 1g with a repeat dose of 1g one week later.
All this time, her abdominal pain is accompanied by loose stools. No blood or mucous. No vomiting.

Returns for follow up and the NP sends her for an EGD and starts her on PPI. EGD returns completely normal. Seen for follow up, stools are now normal and pain persists in both upper quadrants. and I obtain additional labs:

cbc - normal
liver panel - normal
ttg-iga - normal
crp/esr - normal
pANCA - normal
Anti saccharomyces cerivisae (ASCA) IgG returns very positive at 90 (cut off in the 20s ) and IgA is borderline at 22 (normal being <20, and positive being >24).


Question is, does she have Crohn's and is that ASCA result + CT findings (which were not specific in any way for IBD) + ongoing abdominal pain enough to lead us to that? A false positive ASCA is around 5%, although her IgA and IgG levels make it difficult. The negative pANCA supports Crohn's in this context. Ongoing PID seems very unlikely. Inflammation of the mesentery or lymph tissue underneath (which was seen on CT) would subside on its own within a week or two. She very likely doesnt have celiacs based on the ttg-iga. And these symptoms are not tied to diet.

It's been over 2 months now.

Thoughts?
 
Last edited:
  • Like
Reactions: catnip12
Feb 8, 2018
713
1,023
Status
Medical Student
Colonoscopy? Any history of mouth sores, etc.?

Could this be Fitz-Hugh? If so, isn't the only way to find out through diagnostic laparoscopy?
 

Ho0v-man

5+ Year Member
Nov 28, 2014
2,135
5,437
Status
Medical Student
Omental infarction/torsion

tuberculous peritonitis

peritoneal carcinomatosis

prob just crohns
 
Aug 13, 2018
128
129
Status
Medical Student (Accepted)
Giardia infection, perhaps secondary to IgA deficiency? Have you tried an O&P stool screen? What's the travel history?
 
OP
M

Medic_90x

2+ Year Member
Apr 7, 2017
34
5
Status
Medical Student
Omental infarction/torsion

tuberculous peritonitis

peritoneal carcinomatosis

prob just crohns
Omental infarction would be acute and severe pain.

Tuberculous anything - nope.

Peritoneal carcinomatosis, she's 19.

Giardia infection, perhaps secondary to IgA deficiency? Have you tried an O&P stool screen? What's the travel history?
No evidence in the history to suggest Giardia and the stool changes stopped a while ago but did persist during the worst phase of the pain.
Nothing on travel hx.

Could it be Celiac disease even with the negative ttg? Maybe she hadn’t eaten much gluten prior to the test.


Turns out previous PCP in the past worked her up for celiacs already and it was negative. Celiacs would also be more bowel changes rather than pain.
 
  • Like
Reactions: stickgirl390

Ho0v-man

5+ Year Member
Nov 28, 2014
2,135
5,437
Status
Medical Student
Omental infarction would be acute and severe pain.

Tuberculous anything - nope.

Peritoneal carcinomatosis, she's 19.


No evidence in the history to suggest Giardia and the stool changes stopped a while ago but did persist during the worst phase of the pain.
Nothing on travel hx.




Turns out previous PCP in the past worked her up for celiacs already and it was negative. Celiacs would also be more bowel changes rather than pain.
Yeah imaging findings really throw the whole case off. My first guess was just crohns with mesenteric adenitis or epiploic appendigitis but the imaging would be more specific.
 
About the Ads