A 35-year-old male with a history of Crohn’s disease presents with recent onset periumbilical abdominal pain, weight loss, and fever. On physical exam he is noted to have a palpable abdominal mass in the right lower quadrant. What is the appropriate next step in management?
- Administration of corticosteroids
- Administration of methotrexate or azathioprine
- Abdominal plain film
4) Abdominal CT - Surgical consult
explanation
In a patient with Crohn’s disease a palpable mass is concerning for an abdominal abscess and computed tomography (CT) is the diagnostic test of choice.
This patient has a history of Crohn’s disease, a chronic inflammatory bowel disease (IBD) characterized by focal, asymmetric, transmural, and occasionally granulomatous inflammation of the gastrointestinal tract. His symptoms of abdominal pain, weight loss, and fever are all consistent with chronic Crohn’s disease, and offer limited insight into possible exacerbations or alternative diagnoses for his current presentation. The palpable mass found on physical exam is concerning for an intra-abdominal abscess, and must be assessed. The test of choice is abdominal CT with intravenous and oral contrast.
The American College of Gastroenterology Practice Guidelines on the Management of Crohn’s Disease in Adults recommends either transabdominal ultrasound, endoscopic ultrasonography, CT, or MRI to delineate and discriminate intra-abdominal masses, abscesses, or peri-anal complications of Crohn’s disease. A diagnosis of infection or abscess requires appropriate antibiotic therapy in addition to percutaneous or open surgical drainage.
Illustration A is an abdominal CT scan. The large arrow is pointing out an intra-abdominal abscess.