Prevention - how the role of the Family Physician is sometimes as important as making the diagnosis - a case report of Crohn's Disease

Scope
Primary care.

Consultation motive
Involuntary weight loss, diarrhea

Individual focus
This case report is about a 43-year-old woman, caucasian, professionally active, with a known history of thyroid nodules and irritable bowel syndrome (previously negative work-up, with a normal colonoscopy). Cholecystectomised in 2011 due to symptomatic biliary lithiasis, with no other relevant surgical history. With no history of harmful habits such as alcohol, smoking or drugs. No drug allergies reported. Without any chronic medication. The patient presents to her Family Physician with an involuntary 7kg weight loss in 2 months and multiple episodes of watery stools in the past year, increasingly frequent. Denies any mucus, blood or pus in stools. Denies any changes in eating or exercising habits. When asked, the patient mentions previous episodes of watery stools in the past 10 years, with no weight loss or other associated symptoms. The physical exam revealed no relevant findings.

Family and community focus
The patient is divorced, with a reconstituted family consisting of the patient, her companion and her 15-year-old son from a previous marriage – phase 4 accordingly to Carter & McGoldrick’s family life-cycle model (family with teenagers). Good family support and high socio-economical level.

Diagnostic impression
Inflammatory bowel disease? Malabsorption syndrome? Malignant neoplasm?

Plan of action and evolution
The patient was submitted to a battery of tests which included blood analysis for thyroid function, anti-transglutaminase antibodies, IgA, erythrocyte sedimentation rate, and C-reactive protein - all of them negative. The endoscopic exams (upper endoscopy and colonoscopy) revealed ileal ulcerations and an endoscopic pattern suggestive of Crohn’s Disease (CD). The pathology report excludes any findings in the stomach or duodenum, but documents findings in the terminal ileum – ‘ileal mucosa with ulceration areas and fibrine plaques and leucocyte deposition. Polypoid granulation tissue. Lymphoid nodules with activated germinative centres were present’. The patient then opted to make an appointment with a private Gastroenterologist, who suggested doing an MRI-enterography (Magnetic resonance imaging). The exam revealed ‘bowel wall thickening and luminal narrowing, namely in the last ileal loop in a 37mm extension, with several other small zones of segmental wall thickening, eventually linked to inflammatory bowel disease’. The diagnosis of Crohn’s Disease was confirmed and the Gastroenterologist prescribed corticosteroid therapy (budesonide) and the immunomodulator azathioprine. Before starting the medication, the patient was submitted to an infectious diseases’ screening, to exclude latent tuberculosis, Human immunodeficiency virus (HIV), Herpes simplex virus, Hepatitis B and C. Afterwards, the patient returned to the Family Physician and the local Public Health Unit in order to take the needed immunizations prior to immunomodulator therapy - Yellow Fever, Pneumococcal, Hepatitis A and B.

The follow up of Crohn’s Disease will be shared between the Gastroenterologist and the Family Physician, as the patient will need regular medical assessments. The first months of treatment with corticosteroids and immunomodulators require regular blood tests to screen for hemogram changes and eventual lymphoproliferative diseases. Moreover, the patient should have an annual cervical cytology, as the risk of cervical cancer is increased and the human papillomavirus vaccine should be considered – in this case, the patient decided to take it. Measures to protect from sun exposure should be encouraged, as well as an annual dermatology check-up, due to the enhanced risk of melanoma and nonmelanoma skin cancers. The Family Physician should also recommend annual flu vaccination and perform a regular assessment of cardiovascular and thromboembolic risk factors. Smoking avoidance should be positively reinforced and a screening for anxiety and depression should be regularly performed, due to their increased rates in these patients. Due to chronic inflammation and especially in patients taking long courses of corticosteroids, the risk of bone fracture should be assessed using the FRAX® algorithm, and isometric physical exercise should be recommended. Vitamin D supplementation should be administered if needed. An annual ophthalmologic screening should also be provided, due to the increased risk of glaucoma in patients taking long courses of corticosteroids.

Conclusions
Crohn’s Disease is an inflammatory bowel disease with increasing incidence worldwide. Despite the frequent need for immunosuppressive therapy, these patients do not receive adequate preventive care, in comparison with the general population. CD patients, especially when taking immunosuppressive drugs, should have reinforced Primary Care follow-up, as there is a need to oversee complications of the disease itself and to control the side effects of the medication prescribed. The role of the Family Physician begins when the diagnosis is yet unknown and is still of extreme significance on the patient’s follow-up, given the utmost importance of preventive measures (primary, secondary and even tertiary prevention) in these patients.

Keywords
Crohn Disease, Primary Prevention, Secondary Prevention

Bibliography
• Torres, J. et al, Crohn's disease, Lancet. 2017 Apr 29;389(10080):1741-1755.
• Veauthier, B. et al, Crohn's disease: Diagnosis and Management, Am Fam Physician. 2018 Dec 1; 98(11):661-669.