A 28-year-old man comes to the clinic due to a 4-week history of abdominal pain, non-blood… — USMLE Step 2 CK

A $28$ -year-old man comes to the clinic due to a $4$ -week history of abdominal pain, non-bloody diarrhea, and a $4$ -kg ( $8.8$ -lb) weight loss. He has $4$ to $5$ loose bowel movements daily. The abdominal pain is cramping in nature and localizes to the right lower quadrant. He has a history of mild asthma. Vital signs are temperature $37.3^\circ\text{C}$ ( $99.1^\circ\text{F}$ ), pulse $86/\text{min}$ , and blood pressure $118/76\text{ mmHg}$ . Physical examination reveals a soft, non-distended abdomen with moderate tenderness to deep palpation in the right lower quadrant. There is no rebound tenderness, guarding, or palpable mass. Bowel sounds are normal.

Laboratory studies show:

Test	Result	Normal Range
Hemoglobin	$11.2\text{ g/dL}$	$13.5$ - $17.5\text{ g/dL}$
Leukocyte count	$9,400/\text{mm}^3$	$4,500$ - $11,000/\text{mm}^3$
C-reactive protein	$35\text{ mg/L}$	$< 5\text{ mg/L}$

Stool studies for ova and parasites, routine bacterial pathogens, and *Clostridioides difficile* toxin are negative. A recent colonoscopy performed $2$ months ago for chronic diarrhea showed patchy areas of mucosal inflammation, erythema, and deep ulcerations in the terminal ileum, with a normal-appearing colon.

Which of the following is the most appropriate next step in management?

A
Prescribe a course of ciprofloxacin and metronidazole
B
Start intravenous methylprednisolone
C
Recommend a high-fiber diet and oral loperamide
Initiate oral budesonide therapyAnswer
E
Refer the patient for an elective ileocecal resection

Answer

Initiate oral budesonide therapy

The most appropriate next step in management is to initiate oral budesonide therapy. This patient is experiencing a mild-to-moderate flare of Crohn disease, which is localized to the terminal ileum. Budesonide is a potent glucocorticoid that is specifically formulated to release in the distal ileum and right colon. Because it undergoes extensive first-pass hepatic metabolism, it effectively reduces localized mucosal inflammation while causing significantly fewer systemic side effects compared to conventional systemic corticosteroids like prednisone. Therefore, it is the first-line agent for inducing remission in this specific clinical scenario.

Step-by-Step Solution

Identify the patient's primary diagnosis and current disease status.

The patient has a mild-to-moderate flare of Crohn disease localized to the terminal ileum.

He presents with subacute non-bloody diarrhea, right lower quadrant abdominal pain, and weight loss, and recent colonoscopy confirmed terminal ileum involvement without signs of strictures or peritonitis.

Determine the appropriate pharmacotherapy based on disease location and severity.

Oral budesonide is the treatment of choice.

Budesonide is a glucocorticoid with high first-pass hepatic metabolism, providing targeted topical therapy to the terminal ileum and right colon while minimizing systemic side effects.

Key Concept

Oral budesonide is the first-line treatment for inducing remission in patients with mild-to-moderate Crohn disease that is confined to the terminal ileum and/or right colon.

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