The Primary Care Companion for CNS Disorders

CME Institute

Home | About Us | Mission Statement | All CME Activities | MyCME | CME Facebook | CME Twitter

JCP

Home | About JCP | Subscribe | Archive | Information for Authors | Information for Reviewers | Information for Advertisers | CNS Job Market | Customer Service | JCP Facebook | JCP Twitter

PCC

Home | About PCC | Register | Archive | Information for Authors | Information for Reviewers | PCC Facebook | PCC Twitter

Help

FAQ | About Psychiatrist.com | Terms of use | Privacy policy

magnifying glass for search

  • magnifying glass for search
  • Advanced Search

Login

Login  
Login | Login Help | Register | Subscribe
Register | Elerts

Quick Links

Font: A | A | A

Top

Purchase PDF

Vol 12, No 5
Table of Contents

Facebook ShareShare

twitter shareTweet This

envelope iconEmail a link

Related ►

Related Articles

[X]

<p class="frontmatter-fieldnotes disclaimernew" style="margin-bottom:15px;">This work may not be copied, distributed, displayed, published, reproduced, transmitted, modified, posted, sold, licensed, or used for commercial purposes. By downloading this file, you are agreeing to the publisher’s <a href="/pages/termsofuse.aspx" target="_blank">Terms & Conditions</a>.</p> <div id="x10l00955blu">
<div class="story">
<p class="ltrs-br-ltr-br-title">Psychiatric Presentation of a Child With Crohn’s Disease</p>
<p class="ltrs-br-ltr-br-body-text"><span class="bold">To the Editor:</span> Several cases of pediatric onset of Crohn’s disease have presented with psychiatric symptoms, such as depression, anxiety, and abnormal eating behaviors.<span class="htm-cite"><a href="#ref1">1</a>,<a href="#ref2">2</a></span> These patients usually experience delay in diagnosis of the inflammatory bowel disease.<span class="htm-cite"><a href="#ref3">3</a></span> We describe a patient with weight loss and restrictive eating patterns who was admitted to the psychiatric ward and ultimately found to have Crohn’s disease.</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text"><span class="bold-italic">Case report.</span> An 11-year-old boy presented to the emergency department in February 2009 for evaluation of a 6-month history of weight loss of 20 lb (25% of the patient’s body weight). The patient reported diffuse abdominal pain associated with meals, early satiety, restrictive eating patterns, fatigue, and anxiety. On initial examination, the patient’s weight was below the 10th percentile and his height was in the 25th percentile for age. Abdominal examination revealed no distention, tenderness, or guarding. He displayed anxiety at mealtimes, psychomotor agitation, and dysphoric mood without irritability and without suicidal ideation. He was admitted to the child psychiatric ward for further evaluation and management of presumed diagnosis of anorexia nervosa, restrictive type (based on <span class="italic">DSM-IV-TR</span> criteria).</p>
<p class="ltrs-br-ltr-br-body-text">The patient was previously diagnosed with <span class="italic">DSM-IV-TR</span> generalized anxiety disorder and had been under psychiatric care for several years. He was managed with psychotherapy and had been managed with several pharmacologic agents, including olanzapine and bupropion. He had developed a mild microcytic anemia over the months prior to presentation but had no other chronic medical disorders.</p>
<p class="ltrs-br-ltr-br-body-text">Sertraline 12.5 mg daily and clonazepam 0.25 mg at bedtime were initiated to manage the anxiety, and supervised mealtimes were implemented to observe and encourage caloric intake. The patient displayed less dysphoria and anxiety over several days, but reported persistent abdominal pain and anxiety at mealtime and continued losing weight despite taking in 3 meals daily (under staff supervision).</p>
<p class="ltrs-br-ltr-br-body-text">Laboratory evaluation revealed a microcytic anemia and an elevated erythrocyte sedimentation rate of 48 mm/h. The gastroenterology service was consulted, and colonoscopy demonstrated external skin tags, an anal fissure, exudates, and erythema at the terminal ileum. Colon and small bowel biopsy findings were consistent with Crohn’s disease. Treatment with ciprofloxacin 500 mg and lansoprazole 30 mg was initiated. The patient was discharged to follow-up with his outpatient psychiatrist and with a comprehensive care plan for management of new-onset inflammatory bowel disease.</p>
<p class="ltrs-br-ltr-br-body-text">&nbsp;</p>
<p class="ltrs-br-ltr-br-body-text">Inflammatory bowel diseases commonly cause postprandial abdominal pain. This recurrent pain may lead to fear of eating, food avoidance (restrictive eating patterns), and consequent weight loss. Restrictive eating patterns are also characteristic of anorexia nervosa. Physicians observing restrictive eating patterns in patients may not always look for the other characteristics of anorexia nervosa (such as fear of weight gain and body image disturbance) before making a presumptive diagnosis of anorexia nervosa.<span class="htm-cite"><a href="#ref4">4</a></span> This patient’s prior diagnosis of generalized anxiety disorder (based on <span class="italic">DSM-IV-TR</span> criteria) most likely led the team to initially suspect a second psychiatric disorder as an explanation for the weight loss.<span class="htm-cite"><a href="#ref3">3</a></span> This reasoning delayed further diagnostic evaluation, resulting in delayed treatment of Crohn’s disease.</p>
<p class="ltrs-br-ltr-br-references-head">References</p>
<p class="references-references-text-1-9"><a name="ref1"></a>1. Engstrom I. Inflammatory bowel disease in children and adolescents: mental health and family functioning. <span class="italic">J Pediatr Gastroenterol Nutr</span>. 1999;28(4):S28–S33. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10204521&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1097/00005176-199904001-00004">doi:10.1097/00005176-199904001-00004</a></span></p>
<p class="references-references-text-1-9"><a name="ref2"></a>2. Engström I, Lindquist BL. Inflammatory bowel disease in children and adolescents: a somatic and psychiatric investigation. <span class="italic">Acta Paediatr Scand</span>. 1991;80(6–7):640–647. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=1867081&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1111/j.1651-2227.1991.tb11923.x">doi:10.1111/j.1651-2227.1991.tb11923.x</a></span></p>
<p class="references-references-text-1-9"><a name="ref3"></a>3. Rickards H, Prendergast M, Booth IW. Psychiatric presentation of Crohn’s disease: diagnostic delay and increased morbidity. <span class="italic">Br J Psychiatry</span>. 1994;164(2):256–261. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8173832&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1192/bjp.164.2.256">doi:10.1192/bjp.164.2.256</a></span></p>
<p class="references-references-text-1-9"><a name="ref4"></a>4. Mallett P, Murch S. Anorexia nervosa complicating inflammatory bowel disease. <span class="italic">Arch Dis Child</span>. 1990;65(3):298–300. <span class="pubmed-crossref"><a href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=2334208&dopt=Abstract">PubMed</a> <a href="http://dx.doi.org/10.1136/adc.65.3.298">doi:10.1136/adc.65.3.298</a></span></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Mariana Markella, MD</span></p>
<p class="ltrs-br-ltr-br-author"><a href="mailto:mariana.markella@mssm.edu" target="_blank">mariana.markella@mssm.edu</a></p>
<p class="ltrs-br-ltr-br-author"><span class="bold">Joseph M. Cerimele, MD</span></p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Author affiliations:</span> Department of Psychiatry, Mount Sinai School of Medicine, New York, New York.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Potential conflicts of interest: </span>None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Funding/support: </span>None reported.</p>
<p class="ltrs-br-ltr-br-endmatter-fieldnotes"><span class="bold-italic">Published online:</span> September 30, 2010 (<span class="doi">doi:10.4088/PCC.10l00955blu</span>).</p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">Prim Care Companion J Clin Psychiatry 2010;12(5):e1</span></p>
<p class="ltrs-br-ltr-br-copyright-doi"><span class="italic">© Copyright 2010 Physicians Postgraduate Press, Inc.</span></p>
</div>
</div>
Manage Subscriptions
/_layouts/images/ReportServer/Manage_Subscription.gif
/PCC/article/_layouts/ReportServer/ManageSubscriptions.aspx?list={ListId}&ID={ItemId}
0x80
0x0
FileType
rdl
350
Manage Data Sources
/PCC/article/_layouts/ReportServer/DataSourceList.aspx?list={ListId}&ID={ItemId}
0x0
0x20
FileType
rdl
351
Manage Shared Datasets
/PCC/article/_layouts/ReportServer/DatasetList.aspx?list={ListId}&ID={ItemId}
0x0
0x20
FileType
rdl
352
Manage Parameters
/PCC/article/_layouts/ReportServer/ParameterList.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
rdl
353
Manage Processing Options
/PCC/article/_layouts/ReportServer/ReportExecution.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
rdl
354
Manage Cache Refresh Plans
/PCC/article/_layouts/ReportServer/CacheRefreshPlanList.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
rdl
355
View Report History
/PCC/article/_layouts/ReportServer/ReportHistory.aspx?list={ListId}&ID={ItemId}
0x0
0x40
FileType
rdl
356
View Dependent Items
/PCC/article/_layouts/ReportServer/DependentItems.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
rsds
350
Edit Data Source Definition
/PCC/article/_layouts/ReportServer/SharedDataSource.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
rsds
351
View Dependent Items
/PCC/article/_layouts/ReportServer/DependentItems.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
smdl
350
Manage Clickthrough Reports
/PCC/article/_layouts/ReportServer/ModelClickThrough.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
smdl
352
Manage Model Item Security
/PCC/article/_layouts/ReportServer/ModelItemSecurity.aspx?list={ListId}&ID={ItemId}
0x0
0x2000000
FileType
smdl
353
Regenerate Model
/PCC/article/_layouts/ReportServer/GenerateModel.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
smdl
354
Manage Data Sources
/PCC/article/_layouts/ReportServer/DataSourceList.aspx?list={ListId}&ID={ItemId}
0x0
0x20
FileType
smdl
351
Load in Report Builder
/PCC/article/_layouts/ReportServer/RSAction.aspx?RSAction=ReportBuilderModelContext&list={ListId}&ID={ItemId}
0x0
0x2
FileType
smdl
250
Edit in Report Builder
/_layouts/images/ReportServer/EditReport.gif
/PCC/article/_layouts/ReportServer/RSAction.aspx?RSAction=ReportBuilderReportContext&list={ListId}&ID={ItemId}
0x0
0x4
FileType
rdl
250
Edit in Report Builder
/PCC/article/_layouts/ReportServer/RSAction.aspx?RSAction=ReportBuilderDatasetContext&list={ListId}&ID={ItemId}
0x0
0x4
FileType
rsd
250
Manage Caching Options
/PCC/article/_layouts/ReportServer/DatasetCachingOptions.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
rsd
350
Manage Cache Refresh Plans
/PCC/article/_layouts/ReportServer/CacheRefreshPlanList.aspx?list={ListId}&ID={ItemId}&IsDataset=true
0x0
0x4
FileType
rsd
351
Manage Data Sources
/PCC/article/_layouts/ReportServer/DataSourceList.aspx?list={ListId}&ID={ItemId}
0x0
0x20
FileType
rsd
352
View Dependent Items
/PCC/article/_layouts/ReportServer/DependentItems.aspx?list={ListId}&ID={ItemId}
0x0
0x4
FileType
rsd
353
Compliance Details
javascript:commonShowModalDialog('{SiteUrl}/_layouts/itemexpiration.aspx?ID={ItemId}&List={ListId}', 'center:1;dialogHeight:500px;dialogWidth:500px;resizable:yes;status:no;location:no;menubar:no;help:no', function GotoPageAfterClose(pageid){if(pageid == 'hold') {STSNavigate(unescape(decodeURI('{SiteUrl}'))+'/_layouts/hold.aspx?ID={ItemId}&List={ListId}'); return false;} if(pageid == 'audit') {STSNavigate(unescape(decodeURI('{SiteUrl}'))+'/_layouts/Reporting.aspx?Category=Auditing&backtype=item&ID={ItemId}&List={ListId}'); return false;} if(pageid == 'config') {STSNavigate(unescape(decodeURI('{SiteUrl}'))+'/_layouts/expirationconfig.aspx?ID={ItemId}&List={ListId}'); return false;}}, null); return false;
0x0
0x1
ContentType
0x01
898
Document Set Version History
javascript:SP.UI.ModalDialog.ShowPopupDialog('{SiteUrl}/_layouts/DocSetVersions.aspx?List={ListId}&ID={ItemId}')
0x0
0x0
ContentType
0x0120D520
330
Send To other location
javascript:GoToPage('{SiteUrl}/_layouts/docsetsend.aspx?List={ListId}&ID={ItemId}')
0x0
0x0
ContentType
0x0120D520
350

Information Links

Terms of Use | Privacy Policy | Information for Authors (JCP) | Information for Authors (PCC) | Reprints and Permissions | CNS Job Market | Information for Advertisers | Media Relations | PPP COVID-19 Statement

Help

Contact us | Unsubscribe from Elerts | Customer Service | FAQ | About JCP | About PCC | About Psychiatrist.com

Our Family of Sites

Psychiatrist.com | The Journal of Clinical Psychiatry | The Primary Care Companion | The CME Institute | Strong Veterans
Anonymous