Medical management of Crohn's disease US Medical PG Practice Questions and MCQs
Practice US Medical PG questions for Medical management of Crohn's disease. These multiple choice questions (MCQs) cover important concepts and help you prepare for your exams.
Medical management of Crohn's disease US Medical PG Question 1: A 22-year-old woman comes to the physician because of abdominal pain and diarrhea for 2 months. The pain is intermittent, colicky and localized to her right lower quadrant. She has anorexia and fears eating due to the pain. She has lost 4 kg (8.8 lb) during this time. She has no history of a serious illness and takes no medications. Her temperature is 37.8°C (100.0°F), blood pressure 125/65 mm Hg, pulse 75/min, and respirations 14/min. An abdominal examination shows mild tenderness of the right lower quadrant on deep palpation without guarding. Colonoscopy shows small aphthous-like ulcers in the right colon and terminal ileum. Biopsy from the terminal ileum shows noncaseating granulomas in all layers of the bowel wall. Which of the following is the most appropriate pharmacotherapy at this time?
- A. Budesonide (Correct Answer)
- B. Azathioprine
- C. Ciprofloxacin
- D. Metronidazole
- E. Rectal mesalamine
Medical management of Crohn's disease Explanation: ***Budesonide***
- This patient presents with symptoms and findings (RLQ pain, aphthous ulcers, noncaseating granulomas in the terminal ileum) consistent with **Crohn's disease** isolated to the **ileum and right colon**.
- **Budesonide** is a glucocorticoid with high first-pass metabolism, making it effective for localized ileal and right colonic Crohn's disease with fewer systemic side effects than prednisone.
*Azathioprine*
- **Azathioprine** is an immunomodulator used for maintaining remission in moderate to severe Crohn's disease, not typically for acute exacerbations as first-line monotherapy.
- Its onset of action is slow (several weeks to months), making it unsuitable for immediate symptom control.
*Ciprofloxacin*
- **Ciprofloxacin** is an antibiotic mainly used when there is concern for bacterial overgrowth, abscess, or perianal disease in Crohn's, none of which are explicitly indicated here.
- There is no evidence suggesting a primary bacterial infection as the cause of her current symptoms.
*Metronidazole*
- **Metronidazole** is an antibiotic often used for Crohn's disease with perianal involvement or fistulas, and sometimes for active colonic disease, but less effective for ileal involvement.
- Like ciprofloxacin, it's not the primary treatment for uncomplicated flare of ileocolonic Crohn's.
*Rectal mesalamine*
- **Rectal mesalamine** is an aminosalicylate primarily used for mild to moderate **ulcerative colitis**, particularly proctitis or left-sided colitis due to its topical action.
- It is ineffective for Crohn's disease involving the terminal ileum and right colon, as it would not reach this location in sufficient concentration.
Medical management of Crohn's disease US Medical PG Question 2: A 33-year-old woman with Crohn’s disease colitis presents to her physician after 2 days of photophobia and blurred vision. She has had no similar episodes in the past. She has no abdominal pain or diarrhea and takes mesalazine, azathioprine, and prednisone as maintenance therapy. Her vital signs are within normal range. Examination of the eyes shows conjunctival injection. The physical examination is otherwise normal. Slit-lamp examination by an ophthalmologist shows evidence of inflammation in the anterior chamber. Which of the following is the most appropriate modification to this patient’s medication at this time?
- A. Adding infliximab
- B. Increasing dose of prednisone (Correct Answer)
- C. No modification of therapy at this time
- D. Discontinuing mesalazine
- E. Decreasing dose of azathioprine
Medical management of Crohn's disease Explanation: ***Increasing dose of prednisone***
- This patient is presenting with **anterior uveitis**, a common **extraintestinal manifestation of Crohn’s disease**, characterized by photophobia, blurred vision, and inflammation of the anterior chamber.
- **Corticosteroids** (like prednisone) are the **first-line treatment for acute uveitis**, and increasing the dose will help control the inflammation effectively.
*Adding infliximab*
- While **biologics like infliximab** can be effective for refractory uveitis or systemic disease control, they are **not the immediate first-line treatment for an acute uveitis flare**, especially when corticosteroids are already part of the regimen.
- Adding a new biologic would also involve a longer onset of action and additional risks, making it less suitable for urgent symptom control compared to adjusting prednisone.
*No modification of therapy at this time*
- The patient clearly has **acute anterior uveitis**, which is a potentially serious ocular condition requiring prompt treatment to prevent complications such as synechiae, glaucoma, and vision loss.
- Doing nothing would lead to worsening inflammation and potential irreversible damage.
*Discontinuing mesalazine*
- **Mesalazine** (an aminosalicylate) is primarily used for maintaining remission in inflammatory bowel disease and is **not implicated in causing uveitis**, nor is discontinuing it a treatment for uveitis.
- It would also risk a flare of her Crohn's disease.
*Decreasing dose of azathioprine*
- **Azathioprine** is an **immunosuppressant** used to maintain remission in Crohn’s disease and is not a direct treatment for acute uveitis.
- Decreasing the dose would weaken her overall immunosuppression, potentially leading to a flare of her Crohn's disease or making her more susceptible to other issues, without directly addressing the acute ocular inflammation.
Medical management of Crohn's disease US Medical PG Question 3: A 25-year-old man presents with abdominal pain and bloody diarrhea. His symptoms have been recurrent for the past few months, and, currently, he says he is having on average four bowel movements daily, often bloody. He describes the pain as cramping and localized to the left side of his abdomen. He also says that he has lost around 4.5 kg (10 lb) over the past 3 months. There is no other significant past medical history and the patient is not on current medications. His temperature is 37.7° C (100.0° F), pulse rate is 100/min, respiratory rate is 18/min, and blood pressure is 123/85 mm Hg. On physical examination, there is mild tenderness to palpation in the lower left quadrant of the abdomen with no rebound or guarding. Laboratory studies show anemia and thrombocytosis. Colonoscopy is performed, which confirms the diagnosis of ulcerative colitis (UC). What is the mechanism of action of the recommended first-line medication for the treatment of this patient’s condition?
- A. Suppression of cellular and humoral immunity
- B. TNF-⍺ antagonism
- C. Inhibition of enzyme phospholipase A2
- D. Cross-linking of bacterial DNA
- E. Inhibition of leukotriene synthesis and lipoxygenase (Correct Answer)
Medical management of Crohn's disease Explanation: ***Inhibition of leukotriene synthesis and lipoxygenase***
- The first-line medications for mild to moderate ulcerative colitis (UC) are **aminosalicylates** like **mesalamine** (5-ASA).
- Mesalamine is thought to exert its anti-inflammatory effects by inhibiting **leukotriene synthesis** and the **lipoxygenase pathway**, thereby reducing inflammation in the colon.
*Suppression of cellular and humoral immunity*
- This mechanism of action describes **immunosuppressants** such as azathioprine or methotrexate, which are typically used for more severe or refractory cases of UC, not as first-line therapy.
- These drugs broadly suppress the immune system, leading to a higher risk of infections and other side effects.
*TNF-⍺ antagonism*
- This is the mechanism of action of **biologic agents** like infliximab or adalimumab, which are reserved for moderate to severe UC that has not responded to conventional therapy.
- **TNF-α inhibitors** block the inflammatory cytokine TNF-α, reducing inflammation but are not the initial treatment choice.
*Inhibition of enzyme phospholipase A2*
- This mechanism describes **corticosteroids** such as prednisone or budesonide, which are used to induce remission in moderate to severe UC flares, but not as first-line maintenance therapy due to significant side effects.
- Corticosteroids inhibit **phospholipase A2**, thereby blocking the entire arachidonic acid cascade and the production of all inflammatory mediators.
*Cross-linking of bacterial DNA*
- This mechanism describes **antibiotics** like metronidazole or ciprofloxacin, which work by cross-linking DNA in bacteria.
- While antibiotics may be used in specific UC scenarios (such as pouchitis or suspected superimposed infection), UC itself is an idiopathic inflammatory disease, not a bacterial infection, and antibiotics are not first-line treatment for the underlying condition.
Medical management of Crohn's disease US Medical PG Question 4: A 31-year-old man presents to an urgent care clinic with symptoms of lower abdominal pain, bloating, bloody diarrhea, and fullness, all of which have become more frequent over the last 3 months. His vital signs are as follows: blood pressure is 121/81 mm Hg, heart rate is 87/min, and respiratory rate is 15/min. Rectal examination reveals a small amount of bright red blood. Lower endoscopy is performed, showing extensive mucosal erythema, induration, and pseudopolyps extending from the rectum to the splenic flexure. Given the following options, what is the most appropriate initial treatment for this patient's underlying disease?
- A. Azathioprine
- B. Mesalamine (Correct Answer)
- C. Systemic corticosteroids
- D. Total proctocolectomy
- E. Sulfasalazine
Medical management of Crohn's disease Explanation: ***Mesalamine***
- The patient's symptoms (bloody diarrhea, abdominal pain, erythema, pseudopolyps, and inflammation extending from the rectum to the splenic flexure) are highly suggestive of **ulcerative colitis (UC) affecting the left colon (distal colitis)**.
- **Mesalamine** (a 5-aminosalicylic acid or 5-ASA derivative) is the first-line treatment for mild to moderate UC, especially for proctitis and left-sided colitis. Its anti-inflammatory action is exerted topically on the colonic mucosa.
*Azathioprine*
- Azathioprine is an **immunomodulator** used for maintaining remission in UC or in cases where patients are steroid-dependent or refractory to 5-ASAs.
- It is not typically used as a first-line agent for acute, mild to moderate disease.
*Systemic corticosteroids*
- **Systemic corticosteroids** are used for moderate to severe UC or for severe flares, not for initial mild to moderate disease, due to their significant side effect profile.
- While effective in inducing remission, their long-term use is limited, and they are not considered a maintenance therapy.
*Total proctocolectomy*
- **Total proctocolectomy** is a surgical option reserved for severe, refractory UC that does not respond to medical therapy, or in cases of dysplasia/cancer.
- It is an invasive procedure and not an appropriate initial treatment for a patient presenting with symptoms of mild to moderate disease.
*Sulfasalazine*
- **Sulfasalazine** is an older 5-ASA compound that is also effective for mild to moderate UC.
- However, it has a **higher incidence of side effects** (e.g., GI upset, headaches, hypersensitivity) compared to mesalamine, making mesalamine generally preferred for better tolerability.
Medical management of Crohn's disease US Medical PG Question 5: A 28-year-old male presents to his primary care physician with complaints of intermittent abdominal pain and alternating bouts of constipation and diarrhea. His medical chart is not significant for any past medical problems or prior surgeries. He is not prescribed any current medications. Which of the following questions would be the most useful next question in eliciting further history from this patient?
- A. "Does the diarrhea typically precede the constipation, or vice-versa?"
- B. "Is the diarrhea foul-smelling?"
- C. "Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life"
- D. "Are the symptoms worse in the morning or at night?"
- E. "Can you tell me more about the symptoms you have been experiencing?" (Correct Answer)
Medical management of Crohn's disease Explanation: ***Can you tell me more about the symptoms you have been experiencing?***
- This **open-ended question** encourages the patient to provide a **comprehensive narrative** of their symptoms, including details about onset, frequency, duration, alleviating/aggravating factors, and associated symptoms, which is crucial for diagnosis.
- In a patient presenting with vague, intermittent symptoms like alternating constipation and diarrhea, allowing them to elaborate freely can reveal important clues that might not be captured by more targeted questions.
*Does the diarrhea typically precede the constipation, or vice-versa?*
- While knowing the sequence of symptoms can be helpful in understanding the **pattern of bowel dysfunction**, it is a very specific question that might overlook other important aspects of the patient's experience.
- It prematurely narrows the focus without first obtaining a broad understanding of the patient's overall symptomatic picture.
*Is the diarrhea foul-smelling?*
- Foul-smelling diarrhea can indicate **malabsorption** or **bacterial overgrowth**, which are important to consider in some gastrointestinal conditions.
- However, this is a **specific symptom inquiry** that should follow a more general exploration of the patient's symptoms, as it may not be relevant if other crucial details are missed.
*Please rate your abdominal pain on a scale of 1-10, with 10 being the worst pain of your life*
- Quantifying pain intensity is useful for assessing the **severity of discomfort** and monitoring changes over time.
- However, for a patient with intermittent rather than acute, severe pain, understanding the **character, location, and triggers** of the pain is often more diagnostically valuable than just a numerical rating initially.
*Are the symptoms worse in the morning or at night?*
- Diurnal variation can be relevant in certain conditions, such as inflammatory bowel diseases where nocturnal symptoms might be more concerning, or functional disorders whose symptoms might be stress-related.
- This is another **specific question** that should come after gathering a more complete initial picture of the patient's symptoms to ensure no key information is overlooked.
Medical management of Crohn's disease US Medical PG Question 6: A 25-year-old man presents to the emergency department for severe abdominal pain. The patient states that for the past week he has felt fatigued and had a fever. He states that he has had crampy lower abdominal pain and has experienced several bouts of diarrhea. The patient states that his pain is somewhat relieved by defecation. The patient returned from a camping trip 2 weeks ago in the Rocky Mountains. He is concerned that consuming undercooked meats on his trip may have caused this. He admits to consuming beef and chicken cooked over a fire pit. The patient is started on IV fluids and morphine. His temperature is 99.5°F (37.5°C), blood pressure is 130/77 mmHg, pulse is 90/min, respirations are 12/min, and oxygen saturation is 98% on room air. Laboratory studies are ordered and are seen below.
Hemoglobin: 10 g/dL
Hematocrit: 28%
Leukocyte count: 11,500 cells/mm^3 with normal differential
Platelet count: 445,000/mm^3
Serum:
Na+: 140 mEq/L
Cl-: 102 mEq/L
K+: 4.1 mEq/L
HCO3-: 24 mEq/L
BUN: 24 mg/dL
Glucose: 145 mg/dL
Creatinine: 1.4 mg/dL
Ca2+: 9.6 mg/dL
Erythrocyte sedimentation rate (ESR): 75 mm/hour
Physical exam is notable for a patient who appears to be uncomfortable. Gastrointestinal (GI) exam is notable for abdominal pain upon palpation. Ear, nose, and throat exam is notable for multiple painful shallow ulcers in the patient's mouth. Inspection of the patient's lower extremities reveals a pruritic ring-like lesion. Cardiac and pulmonary exams are within normal limits. Which of the following best describes this patient's underlying condition?
- A. p-ANCA positive autoimmune bowel disease
- B. Transmural granulomas in the bowel (Correct Answer)
- C. Gram-negative microaerophilic organism
- D. Rectal mucosa outpouching
- E. Bowel wall spasticity
Medical management of Crohn's disease Explanation: ***Transmural granulomas in the bowel***
- This patient's symptoms, including **chronic diarrhea**, **abdominal pain relieved by defecation**, **oral ulcers**, **fatigue**, **fever**, and **elevated ESR**, along with a **pruritic ring-like lesion** (suggestive of erythema nodosum, a common extraintestinal manifestation), are highly indicative of **Crohn's disease**.
- **Crohn's disease** is characterized by **transmural inflammation** of any part of the GI tract, often with the formation of **non-caseating granulomas**.
*p-ANCA positive autoimmune bowel disease*
- This describes **ulcerative colitis**, which is typically associated with **p-ANCA positivity** in a subset of patients.
- Unlike the diffuse and continuous inflammation seen in ulcerative colitis, Crohn's disease features **skip lesions** and **transmural inflammation**, which aligns better with the varied symptoms and extraintestinal manifestations presented.
*Gram-negative microaerophilic organism*
- This refers to bacterial infections such as those caused by **Campylobacter jejuni** or **Helicobacter pylori**, which can cause GI symptoms.
- While the patient's camping trip and consumption of undercooked meat might suggest an infectious etiology, the **chronic nature of symptoms** (week-long fatigue and fever), **oral ulcers**, **elevated ESR**, and **erythema nodosum-like lesion** point more strongly towards an autoimmune/inflammatory bowel disease rather than an acute bacterial infection.
*Rectal mucosa outpouching*
- **Diverticula** are outpouchings of the colon, commonly affecting the sigmoid colon, and are typically associated with **diverticulitis** when inflamed.
- This condition does not explain the widespread systemic symptoms, oral ulcers, or the chronic, crampy abdominal pain and diarrhea pattern seen in this patient.
*Bowel wall spasticity*
- **Bowel spasticity** is a feature of **irritable bowel syndrome (IBS)**.
- While IBS can cause crampy abdominal pain and changes in bowel habits, it is a **functional disorder** and does not cause **fever**, **oral ulcers**, **elevated ESR**, or significant **anemia** and **thrombocytosis** as seen in this patient.
Medical management of Crohn's disease US Medical PG Question 7: A 22-year-old man presents to the emergency department with abdominal pain. The patient states that he has had right lower quadrant abdominal pain for "a while now". The pain comes and goes, and today it is particularly painful. The patient is a college student studying philosophy. He drinks alcohol occasionally and is currently sexually active. He states that sometimes he feels anxious about school. The patient's father died of colon cancer at the age of 55, and his mother died of breast cancer when she was 57. The patient has a past medical history of anxiety and depression which is not currently treated. Review of systems is positive for bloody diarrhea. His temperature is 99.5°F (37.5°C), blood pressure is 100/58 mmHg, pulse is 120/min, respirations are 17/min, and oxygen saturation is 98% on room air. Cardiopulmonary exam is within normal limits. Abdominal exam reveals diffuse tenderness. A fecal occult blood test is positive. Which of the following is the most likely diagnosis?
- A. Irritable bowel syndrome
- B. Colon cancer
- C. Appendicitis
- D. Infectious colitis
- E. Inflammatory bowel disease (IBD) (Correct Answer)
Medical management of Crohn's disease Explanation: ***Inflammatory bowel disease (IBD)***
- The patient's presentation with **recurrent right lower quadrant pain**, **bloody diarrhea**, a **positive fecal occult blood test**, and a family history concerning for GI issues (colon cancer in father) in a young adult is highly suggestive of IBD, specifically **Crohn's disease** due to the RLQ pain location.
- His history of anxiety and depression is common in IBD patients, and the elevated pulse with mild hypotension suggests **volume depletion** from bloody diarrhea, a common complication.
*Irritable bowel syndrome*
- While IBS can cause recurrent abdominal pain, it is characterized by **functional bowel changes** and typically does not present with **bloody diarrhea** or a positive fecal occult blood test.
- IBS symptoms are often relieved by defecation and are not usually associated with significant systemic inflammation or blood loss.
*Colon cancer*
- Colon cancer is less likely in a **22-year-old** presenting with these acute symptoms, despite the family history, as it typically affects older individuals.
- While it can cause bloody stools and abdominal pain, the **recurrent nature** and acute presentation with bloody diarrhea are more classic for IBD in this age group.
*Appendicitis*
- Appendicitis presents with acute, **migratory right lower quadrant pain** that typically progresses and worsens over hours to a day, often with fever and leukocytosis.
- The given history of pain for "**a while now**" and bloody diarrhea makes appendicitis an unlikely primary diagnosis.
*Infectious colitis*
- Infectious colitis can cause abdominal pain and bloody diarrhea, but it's usually **acute in onset** without a long history of recurrent symptoms.
- While possible, the **recurrent nature** of the pain and bloody diarrhea for "**a while now**" makes a chronic condition like IBD more probable.
Medical management of Crohn's disease US Medical PG Question 8: A 28-year-old woman comes to the physician because of a 2-month history of multiple right inframammary lumps. They are tender and have a foul-smelling odor. She has had previous episodes of painful swellings in the axillae 12 months ago that resolved with antibiotic therapy, leaving some scarring. She has Crohn disease. Menses occur at irregular 18- to 40-day intervals and last 1–5 days. The patient's only medication is mesalamine. She appears anxious. She is 162 cm (5 ft 4 in) tall and weighs 87 kg (192 lb); BMI is 33 kg/m2. Vital signs are within normal limits. Examination of the right inframammary fold shows multiple tender, erythematous nodules and fistulas with purulent discharge. Hirsutism is present. Her fasting glucose concentration is 136 mg/dL. Which of the following areas is most likely to also be affected by this patient's condition?
- A. Forehead
- B. Back
- C. Shin
- D. Central face
- E. Groin (Correct Answer)
Medical management of Crohn's disease Explanation: ***Groin***
- The patient's presentation with recurrent tender, foul-smelling lumps in the **inframammary fold** and past episodes in the **axillae**, along with scarring, strongly suggests **hidradenitis suppurativa (HS)**. HS commonly affects areas with a high density of apocrine glands, including the **axillae, groin, inframammary folds**, and anogenital region.
- Her history of **Crohn disease**, obesity (BMI 33 kg/m²), and possible insulin resistance (fasting glucose 136 mg/dL) are all associated risk factors for HS. The groin is another typical site for lesions.
*Forehead*
- The forehead is generally considered part of the **T-zone of the face**, where sebaceous glands are abundant, but it is not a primary site for *hidradenitis suppurativa*.
- Lesions in this area are more commonly associated with **acne vulgaris** or other folliculitis, which typically present differently.
*Back*
- While the back can be affected by various follicular conditions like **acne inversa** or folliculitis, it is not a primary or highly characteristic site for the deep, painful, and recurring lesions of *hidradenitis suppurativa* in the way intertriginous areas are.
- The specific pattern of involvement in **skin folds** points away from the broader back area as an equally likely site.
*Shin*
- The shins are not typically affected by *hidradenitis suppurativa* as they lack the high concentration of **apocrine glands** found in the classic affected areas.
- Lesions on the shin are more characteristic of conditions like **erythema nodosum** or other forms of vasculitis, which have different presentations.
*Central face*
- The central face, like the forehead, is rich in **sebaceous glands** and is a common site for conditions like **acne vulgaris** or rosacea.
- However, it is not a typical anatomical location for the characteristic deep, recurrent abscesses and sinus tracts seen in *hidradenitis suppurativa*.
Medical management of Crohn's disease US Medical PG Question 9: A 44-year-old woman comes to the physician with increasingly yellow sclera and pruritus over the past 3 months. She has intermittent right-upper-quadrant pain and discomfort. She has no history of any serious illnesses and takes no medications. Her vital signs are within normal limits. Her sclera are icteric. Skin examination shows linear scratch marks on the trunk and limbs. The remainder of the physical examination is unremarkable. Laboratory studies show:
Complete blood count
Hemoglobin 15 g/dL
Mean corpuscular volume 95 μm3
Leukocyte count 6,000/mm3 with a normal differential
Serum
Alkaline phosphatase 470 U/L
Aspartate aminotransferase (AST, GOT) 38 U/L
Alanine aminotransferase (ALT, GPT) 45 U/L
γ-Glutamyltransferase (GGT) 83 U/L (N=5–50 U/L)
Bilirubin, total 2.7 mg/dL
Bilirubin, direct 1.4 mg/dL
Magnetic resonance cholangiopancreatography (MRCP) shows a multifocal and diffuse beaded appearance of the intrahepatic and extrahepatic biliary ducts. Which of the following is the most appropriate diagnostic study at this time?
- A. No further testing is indicated
- B. Colonoscopy (Correct Answer)
- C. Liver biopsy
- D. Upper endoscopy
- E. Endoscopic retrograde cholangiopancreatography (ERCP)
Medical management of Crohn's disease Explanation: ***Colonoscopy***
- The patient's presentation with **pruritus**, **jaundice**, elevated **alkaline phosphatase**, and characteristic **beaded appearance of biliary ducts** on MRCP is highly suggestive of **Primary Sclerosing Cholangitis (PSC)**.
- Approximately **60-80% of patients with PSC** have concomitant **inflammatory bowel disease (IBD)**, particularly **ulcerative colitis**.
- **Colonoscopy with biopsies** is the most appropriate next step to screen for IBD, as it allows visualization of the entire colon and can detect pancolitis or right-sided disease that would be missed by sigmoidoscopy.
- Early detection of IBD is important for management and colorectal cancer surveillance, as PSC-IBD patients have increased risk of colorectal malignancy.
*No further testing is indicated*
- This is incorrect because the patient has clear signs of PSC, and further evaluation is necessary to screen for **associated IBD**, which occurs in the majority of PSC patients.
- Identifying concurrent IBD affects prognosis, management, and surveillance strategies for colorectal cancer.
*Liver biopsy*
- While liver biopsy can provide histological confirmation and staging information, the **MRCP findings of multifocal beaded strictures** are highly specific for PSC and are generally considered **diagnostic**.
- Biopsy carries risks and is typically reserved for cases where imaging is equivocal or when assessing fibrosis stage is critical for management decisions.
- Given the classic MRCP findings, screening for IBD takes priority over liver biopsy.
*Upper endoscopy*
- **Upper endoscopy** evaluates the esophagus, stomach, and duodenum.
- It is not appropriate for screening inflammatory bowel disease or evaluating the biliary tree in the context of suspected PSC.
- Upper endoscopy would be indicated if the patient had upper GI symptoms or if screening for varices was needed in cirrhotic patients.
*Endoscopic retrograde cholangiopancreatography (ERCP)*
- While **ERCP** can visualize the biliary tree, it is an **invasive procedure** with significant risks including **pancreatitis** (3-5% risk), cholangitis, and perforation.
- Given that **MRCP has already demonstrated the characteristic findings** of PSC non-invasively, ERCP is reserved for **therapeutic interventions** (e.g., balloon dilation of dominant strictures, stent placement, or bile duct brushings if cholangiocarcinoma is suspected).
- ERCP is not appropriate as a diagnostic study when MRCP has already established the diagnosis.
Medical management of Crohn's disease US Medical PG Question 10: A 38-year-old woman with a history of Crohn’s disease presents with a 3-week history of weight gain. The patient also presents with a 1-month history of abdominal pain, cramping, and bloody diarrhea consistent with worsening of her inflammatory bowel disease. Past medical history is significant for Crohn’s disease diagnosed 2 years ago for which she currently takes an oral medication daily and intermittently receives intravenous medication she cannot recall the name of. Her temperature is 37.0°C (98.6°F), blood pressure is 120/90 mm Hg, pulse is 68/min, respiratory rate is 14/min, and oxygen saturation is 99% on room air. Physical examination reveals significant truncal weight gain. The patient has excessive facial hair in addition to purplish striae on her abdomen. Which of the following laboratory findings would most likely be found in this patient?
- A. Hyperglycemia (Correct Answer)
- B. Hypoglycemia
- C. Metabolic acidosis
- D. Hyperkalemia
- E. Hypokalemia
Medical management of Crohn's disease Explanation: ***Hyperglycemia***
- The patient exhibits **Cushing's syndrome** due to chronic corticosteroid use for Crohn's disease, with classic features including truncal obesity, hirsutism, and purplish striae.
- **Hyperglycemia is the most common and expected metabolic abnormality** with chronic glucocorticoid therapy, occurring in 30-40% of patients.
- Glucocorticoids cause hyperglycemia by **increasing gluconeogenesis**, **promoting glycogenolysis**, and **inducing insulin resistance** in peripheral tissues.
- This is a direct and prominent effect of glucocorticoid excess, making it the most likely laboratory finding in this clinical scenario.
*Hypokalemia*
- While possible with high-dose corticosteroids, hypokalemia is **less common** with modern synthetic glucocorticoids (prednisone, methylprednisolone) which have minimal mineralocorticoid activity.
- Hypokalemia primarily occurs with corticosteroids having significant mineralocorticoid effects (hydrocortisone, cortisone) or at very high doses.
- Compared to hyperglycemia, this is not the "most likely" finding in typical glucocorticoid therapy.
*Hypoglycemia*
- Glucocorticoids cause **hyperglycemia**, not hypoglycemia, due to their counter-regulatory effects on glucose metabolism.
- This is the opposite of what occurs with steroid excess.
*Metabolic acidosis*
- **Metabolic alkalosis**, not acidosis, can occur with Cushing's syndrome due to mineralocorticoid effects promoting hydrogen ion excretion.
- The hypokalemia that may develop is typically accompanied by alkalosis, not acidosis.
*Hyperkalemia*
- Glucocorticoids promote **potassium excretion** through mineralocorticoid receptor activation, making hyperkalemia unlikely.
- This would contradict the known effects of corticosteroid excess.
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