Visual Diagnosis

Presentation

A 17-year-old girl presents to the pediatric gastroenterology clinic with a 4-day history of intermittent crampy, bilateral lower quadrant abdominal pain associated with nausea and nonbloody, nonbilious emesis. She had Crohn disease (CD) diagnosed at 15 years of age. At the time of her initial presentation of CD, abnormal laboratory findings included an elevated erythrocyte sedimentation rate, marked mucosal irregularity demonstrated by upper gastrointestinal barium series with small bowel follow-through, and chronic inflammation of the colon documented during colonoscopy. The terminal ileum could not be seen at that time. The patient responded well to oral mesalamine therapy, but she self-terminated her medication sometime prior to this clinic visit. The patient and family state that there are no psychosocial stressors.

On physical examination, the girl's vital signs are normal for age, and she has abdominal distention with tenderness and a palpable mass in the right lower quadrant. A plain abdominal radiograph reveals a radiopaque density in the right lower quadrant of the abdomen (Fig. 1). A subsequent abdominal computed tomography scan demonstrates prominent bowel wall edema of the distal ileum believed to be due to bowel wall inflammation, accumulated fecal material, and possible small bowel obstruction (Fig. 2). Laboratory data show a mild microcytic anemia with hemoglobin of 10.7 g/dL (107 g/L) (normal, 12 to 16 g/dL [12 to 16 g/L]), hematocrit of 33.2% (0.332) (normal, 36% to 46% [0.36 to 0.46]), red blood cell distribution width of 16.1% (normal, 11% to 15%), and mean red blood cell volume of 71.5 fL (normal, 78 to 102 fL). C-reactive protein is elevated at 132 mg/L (13.2 mg/dL) (normal female, 15 to 28 years, 0.20 to 1.90 mg/L [0.02 to 0.19 mg/dL]), although serum lactate dehydrogenase, uric acid, erythrocyte sedimentation rate, amylase, and lipase values are within normal limits.