a17years old female diagnosed as acse of coeliac disease+bowel inflammatory disease(chrons)-on gluteen free diet +azathiopurine 1000mg od+mv-she stopped her azathioprine without knowledge of her doctor-from 5 days she was c\o abdominal pain-severe nausea-severe backache-neck pain not improving by injectable steroids-no pain-iv fluid-buscpan-what is possible diagnosis and management.
Rule out - exacerbation of her primary condition i.e Crohn's - think of other causes of acute abdomen ( appendicitis, ac. pancreatitis, stones ( kidney and gall bladder ), and perforation esp. from Crohn's - rule out subacute intestinal obstruction from strictures - rule out meningitis ( both septic and aseptic ) - note: certain drugs can cause aseptic meningitis ( ex. brufen and Azathioprine ). Since she has stopped azathioprine that may not be the cause in her case. Brufen is esp. notorious for causing aseptic meningitis in SLE patients. - rule out acute intermittent porphyria Note: The perforation may be very small and buried in the mucosa that it may not be visible on colonoscopy...so u hav to do a CT and look for any collection ( the CT will not show a perforation, but any adhesion or matting of intestines or any fluid collection will point towards a perforation ) I hope ur patient does well. (Y) Keep us posted p.s Additionally since Crohn's can affect anywhere from mouth to anus ....do a gastroduodenoscopy to rule out any upper gi ulcerative process and start a trial of Proton pump inhibitors, irrespective of the findings. Stat CT abdomen and pelvis is must....becos u don't want a septicemia ( hot potato ).
