123 The Cost of Inequity: Socioeconomic Barriers and Poor Outcomes in Crohn’s Disease – A Case Report

Introduction: Low socioeconomic status impacts patient access to healthcare and contributes to worse health outcomes. We present a case of a young uninsured Hispanic patient with low socioeconomic status that led to a poor outcome of Crohn’s disease. Case Description: This is a 25-year-old male with a history of Crohn’s disease complicated by small bowel resection in 2018, who presented with diarrhea (15 episodes per day) including nocturnal episodes, hematochezia, abdominal pain, fatigue, low appetite, and unintentional weight loss. The patient had not followed with a gastroenterologist or primary care provider for years due to lack of insurance. He was not on any medications. On exam, BMI was 14 with evidence of loss of subcutaneous fat and muscle. Lab revealed microcytic hypochromic anemia (hemoglobin 6.3 g/dL), hypoalbuminemia (3 g/dL), severe vitamin D deficiency (6 ng/mL), elevated CRP (77.5 mg/L) and fecal calprotectin (941 µg/g). CT abdomen/pelvis showed acute on chronic pancolitis. Bidirectional endoscopy was pursued while inpatient. EGD was unremarkable. Colonoscopy revealed significant inflammation and aphthous ulcers in ileum and throughout the colon with descending colon stricture, equating to a Simple Endoscopic Score for Crohn's Disease of 24 and Rutgeert's score of i1. A laparoscopic loop ileostomy for fecal diversion for complicated Crohn's disease was performed to reduce colon inflammation. Post operative course was complicated by ileus, and persistent severe malnutrition requiring ongoing total parenteral nutrition. He was ultimately discharged home with rehabilitation and Inflammatory bowel diseases (IBD) clinic follow-up with a plan to start biologic therapy to attempt salvage of the diverted colon segment. Discussion: This case highlights how social determinants of health can shape IBD outcomes. Delayed diagnosis and treatment of IBD can further worsen prognosis. Prolonged untreated disease increases the risk of strictures, fistulas, abscesses and cumulative bowel damage, often necessitating surgery. Delayed initiation of biologics lowers remission rates, increases steroid dependence and worsens quality of life. Similarly, longer delays between diagnosis and surgery raise the risk of postoperative complications such as anastomotic leak, whereas early surgery reduces reoperation rates. In this case, years without therapy led to severe malnutrition and ultimately an avoidable surgical diversion. Financial Assistance Programs (FAPs) have been shown to mitigate these disparities by improving access to biologics. Patients enrolled in FAPs present with less complex Crohn’s disease, undergo fewer surgeries and have lower surgical risk. By enabling earlier therapy, FAPs help prevent progression and reduce complications. Our patient’s lack of financial support perpetuated untreated inflammation and contributed to disease escalation. Overall, this case demonstrates how lack of insurance and healthcare access can drive Crohn’s disease to advanced stages requiring surgery. Social determinants of health are independently linked to poorer outcomes, reflecting both systemic inequities and patient-level barriers such as limited health literacy and adherence. Addressing these gaps requires systemic reforms, early specialist referral, equitable access to advanced treatments, and financial support programs. Multidisciplinary strategies are essential to reduce morbidity and improve long-term outcomes.