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| Case of the Week Thursday 18/10/2005 |
Presented by Dr. Aisha El Sharkawy .
Crohn's Disease
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STAFF ROUND PRESENTATION
Members of the unit
Prof. Dr. Hosney Salama.
Prof. Dr. Iman Medhat.
Prof. Dr. Hanan Abdelhalim.
Dr.Salwa Mokhtar.
Dr. Rasha Ahmed.
Dr. Sherif Hamdy.
Dr. Wael Fathy.
Dr. Zainab Zakaria.
Dr. M Orfi
Dr. M Ebeed.
Personal history:
A female patient, Reda Abdel-Tawab, 35 years old, married 13 years ago, having only one daughter 12 yeas old.
She is a housewife, she was born & lived in Fayom for 22 years but now she is living in Helwan( cairo ).
There is a history of contact with canal water but no other special habits of medical importance.
Menstrual history:
Menarche at the age of 13 with history of regular cycles till hysterectomy was done following the delivery of her daughter due to rupture uterus.
No history of use of any method of contraception.
Complaint:
Passage of frequent loose stools.
Present history:
The condition started one year ago by gradual onset & progressive course of watery diarrhea, large in amount, about 8-10 motions/day, 2 motions of them awaken the patient from sleep, with no mucus, blood or tenesmus.
It was associated with colicky ,central abdominal pain , not related to meals & not relieved by defecation.
There was no symptoms suggestive of upper GIT affection or hepato-biliary affection.
The condition was associated with loss of weight ,about 20 kg during this year, with no history of fever or perception of body masses.
• The patient is not known to be diabetic.
• No symptoms suggestive of cardiac or pulmonary affection.
• No urological symptoms.
• No musculoskeletal, skin, or ocular symptoms.
She sought medical advice & was given oral metronidazole with no improvement & was told to have a cardiac problem (mitral regurge) that needs valve replacement.
And so, she did mitral valve replacement 9 months ago & since then she was on oral anticoagulant therapy.
One month later, the patient developed a severe attack of bleeding per rectum, lasting for 2 days for which she was admitted to the hospital & received blood transfusion.
Upper endoscopy & colonoscopy was done with no bleeding source or any other abnormality could be detected.
Another attack of bleeding per rectum occurred during her hospital stay in our department, 2 weeks after admission, which was massive, and lasted for 2 days.
During this attack, the patient was shocked, hypotensive thus transferred to our ICU, where anticoagulant therapy was stopped & She was given blood & plasma transfusion till she was resuscitated.
After the patient relieved from this attack, she was still complaining of the diarrhea with no change of any of her symptoms.
Family history: • n No similar condition .
• n -ve consanguinity.
• n No family history of T.B.
Past history:
• History of rheumatic fever at the age of 11, for which she received two penicillin injections then she stopped taking it.
• At the age of 23, she started to take penicillin again till the age of 30.
• Appendicectomy was done 15 years ago.
• Hysterectomy was done 12 years ago.
• No history of T.B or admission to fever hospital.
• History of receiving anti-schistosomal treatment in the form of tablets.
• No history of drug intake .
Summary
A female , cardiac patient, 35 years old complaining of chronic, organic, watery diarrhea mostly of small intestinal origin, with loss of weight & two attacks of bleeding per rectum.
General examination:
-The patient is fully conscious, co-operative, average intelligence & well oriented to time, place & persons.
-She is lying comfortable in bed.
-She is underweight (39 Kg).
-Height:154 cm .
-Pulse: 88/min
-Temp: 37 °C (all through hospital stay)
-BP: 110/70
• Pallor.
• No cyanosis & no jaundice.
• No thyroid swelling & no lymphadenopathy.
• Ocular examination : free.
• Upper limb :
• Pallor.
• Ecchymotic patches at site of injections.
• No skin lesions.
• Lower limbs : bilateral mild oedema.
Abdominal examination:
• Normal shape, no divarication of recti, acute subcostal angle, umbilicus in place & inverted.
• Scar of previous appendicectomy, 5 cm, healing by 1ry intension.
• Scar of hysterectomy, 8 cm healing by 1ry intension.
• Liver:
• Upper border: 5th space MCL.
• Rt lobe: not felt.
• Lt lobe: 4 cm dullness below xiphisternal junction.
• Spleen: not felt.
• No ascites detected clinically.
Cardiac examination:
• Metallic click of the mitral prosthesis is well heard.
• Normal S2, no pulsations, no additional sounds & no murmurs.
Chest examination:
• Free apart from a scar of median sternotomy,15 cm long
Neurological & musculoskeletal examination:
- Clinically free
Differential Diagnosis
• Infections
T.B
Giardia
Capillaria
HIV
• Inflammatory
Inflammatory bowel disease.
Ischemic enteritis
• Neoplasm
Lymphoma of small intestine
Carcinoid
• Endocrine
Hyperthyroidism
Diabetes
Medullary carcinoma of the thyroid
Gastrinoma
• Other
Celiac
Whipple ' s
Amyloid
Drugs(Laxatives, . .)
URINALYSIS:
• Protien: Nil.
• Glucose: Nil.
• Bile pigment : Nil.
• Pus cells: 1-2/HPF
• No RBCs, casts, crystals or ova .
Stool analysis:
(It was repeated 6 times)
• Consistency: loose, soft.
• Mucus: nil.
• Blood: nil.
• Colour: brown.
• Odour: faecal.
• Reaction: alkaline.
• No pus cells, no RBCs, no protozoa, no ova.
Z.N IN STOOLS
(Repeated 3 successive days)
• No acid fast bacilli could be detected.
STOOLS CULTURE
• No growth.
• Negative for campylobacter & yersenia enterocolitica.
• Negative for T.B
CBC:
• RBCs: 2.8 million
• HGB: 8.9 gm%
• MCV: 85 fl.
• MCH: 28 pg.
• MCHC: 33 g/dl.
• PLT: 350,000.
• WBCS: 5000
• B: 1
• E :1
• St: 3
• Seg: 60
• LYMPH: 30
• MONO: 5
ESR (Corrected):
• 1st hour: 48 mm
• 2nd hour: 69mm
LIVER FUNCTIONS:
• BIL T: 0.3 mg/dl (0.2-1.2)
• AST: 21 u/l (0-41)
• ALT: 20 u/l (0-41)
• TOTAL POTEINS: 4.2.g/dl. (6.4-8.3)
• ALBUMIN: 1.6 g/dl (3.5-5)
• ALP: 104 u/l (40-150)
• PT : 30 sec
• Control: 12.2 sec
• PC: 22%
• INR: 2.5
However..
INR was maintained between 2.5-3.5
RENAL FUNCTIONS:
• Urea: 41 mg/dl (10-50)
• Creatinine: 0.6 mg/dl (0.7-1.3)
Serum electrolytes
• Na: 130 mEq/L
• K:
• On admission was 2.5 mEq/L
• With K supplementation: 4.5
• FBS: 90
• 2 hours post prandial blood sugar: 130
HIV :
• Negative
Thyroid functions:
• Free T3 : 2.0 N(1.3-5) pg/ml
• Free T4: 1.1 N(0.8-2)pg/ml.
• TSH: 2.8 N(0.4-4)pg/ml
Screening for auto-antibodies:
• Antigliadin IgG: negative.
• Anti-endomysial: negative.
• Anti tissue transglutaminse: negtive.
• Tuberculin test: negative.
• Chest x ray:
• Free apart from :
Evidence of open heart surgery and mitral valve replacement.
ABDOMINAL U/S:
• Liver: average in size. bright ecchopattern, smooth surface & normal hepatic veins, no focal lesions or IHBR dilatation. P.V is not dilated.
• G.B : average in size & wall thickness, no stones or mud inside . CBD is not dilated.
• Spleen: average in size ,homogenous ecchopattern.
• Kidney: average in size, parenchymal echogenecity, no typical calculi or back pressure changes.
• Pancreas: Free.
• No abdominal lymphadenopathy.
• Few dilated intestinal loops are noted, especially in the lower abdomen. Their walls are not thickened &they are mobile.
• There is a minimal amount of free fluid seen between these loops as well in the cul-de-sac.
Conclusion:
• Few dilated intestinal loops.
• Minimal amount of intra-abdominal free fluid.
Upper GIT endoscopy:
• Stomach: mucosa of the fundus &body are free. Mucosa of the antrum show scattered hyperemic patches.
• Pyloric ring: normal.
• Duodenum: Free down to the second part. Aspirate &biopsies were taken.
• Conclusion:
Mild antral gastritis
Pathology of the duodenal biopsy:
Examination of specimen received revealed multiple duodenal mucosal fragments showing mild infiltration of the lamina propria by chronic inflammatory cells with no evidence of specefic infection or neoplasia.
Mild chronic duodenitis
Duodenal aspirate
• Negative for capillaria, giardia or any other parasites.
Colonoscopy
• It was done up to the terminal ileum.
• The exposed mucosa show no mucosal abnormality.
• Terminal ileal biopsies were taken.
Pathology
• There were shortening & broadening of the villi.
• Lamina propria & submucosa were oedematous &showed moderate infiltration by chronic inflammatory cells.
• No malignancy.
Chronic enteritis with villous atrophy
BMFT
• Coarse intestinal mucosal lining.
• Displaced & separated bowel loops.
• Multiple nodular filling defects & aneurysmal dilatation of the distal jejunal loops &ileum with stricture segment is seen.
• Findings are highly suggestive of intestinal lymphoma.
Enteroscopy
• Introduction of the scope was done till the mid jejunum.
• No gross abnormality was detected.
• Biopsies were taken.
Pathology of the jejunal biopsy:
• Edematous congested villi with moderate infiltration by lymphocytes &plasma cells.
Mild chronic jejunitis
Now .
and after all these investigations
what will we do?
How can we reach that lesion in the distal jejunum & ileum after failure of endoscopies to reach?
Now..
It is time for surgery.
• She was referred to surgery & mini-laparotomy was done to her.
• Resection anastmosis was done to a part of ilem.
It was sent to the pathology& a longitudinal section was done showing ... ..
• Gross: intestinal segment showed a stenotic point followed by a dilated segment
• On opening there were multiple variable sized polypoid structures .
• Dissection of the mesentric fat revealed 4 nodules.
Microscopic:
• Segment of the small intestine show ulceratins, fissure ulcers, pseudopolypi,dense transmural inflammatory infiltrate extending to serosa, oedematous thickened submucosa with hypertrophied muscle layer, alternating segments with normal mucosal lining &oedematous submucosa.
• Non caseating granulomas.
• Reactive hyperplastic draining lymph nodes.
• No malignancy.
Diagnosis
Crohn ' s disease ,small intestinal
Thank you
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