PLACE : Shariati hospital- Shahid Peyroviani hall

CASE:  

      A 23  y/o man from Dashte moghan  ,with severe debilitating  colicky abdominal pain and weight loss for  months , remained  undiagnosed.Not smoker, not alcohol userNot smoker, not alcohol user

PAST MEDICAL HISTORY

He had mild colicky periumbilical  abdominal pain lasting for few minutes associated with bloating intermittently about 1.5 years ago.He had not any physician visit at that time but  the pain became aggravated since 4 months .

The pain attacks interval was every 1-2 weeks, was colicky and severe, lasting few hours  and was associated with nausea and vomiting and then weight loss added to the problems: 15 kg/4 months.

FAMILY HISTORY: neg

3 Months ago, because of severity of the pain, he was admitted in Ardabil  hospital and some diagnostic work up was done:  

Ø      WBC:11,600  N:83  L:17 , HGB:11  HCT:36.4 PLT:328,000

Ø      U/A:NL

Ø      LFT: NL

Ø      NL CT of abdomen

Ø       NL colonoscopy

Ø      EGD: focal hyperemia in proximal part  of stomach

He was discharged with diagnosis of small bowel lesion with Ranitidine, Hyoscine and Mesalazine TDS, with referring to Tehran for enteroscopy.

He did double balloon enteroscopy  in Fayyazbakhsh hospital, and then was referred to Shariati hospital and admitted.

MEDICATION HISTORY

During this 3 months  : Metronidazole 250 mg TDS          

                                     Mezalazine 500 mg TDS                   

                                     Doxycyclin 100 mg Bid

 

PHYSICAL EXAMINATION

Despite history of severe weight loss, he was not emaciated but was seemed ill .

Abdominal examination was normal

No any positive finding except of pallor

OUR LABORATORY

�        WBC: 3,500   HGB: 7.4   MCV:83   PLT: 99,000

�        ESR: 25   CRP: 24

�        LDH:  342

�        SI: 83   TIBC: 271

Double balloon enteroscopy

 The lumen of jejunum was dilated and the secretions was too malodorous to continuing the procedure, biopsy from jejunum was taken with report of : Acute on chronic jejunitis

Total colonoscopy and terminal ileoscopy reported normal.

diagnosis

Crohn's disease

DISCARGING

We discharged him with :

Prednisolon 50 mg/d

Ca-D bid

 After one month :

 the pain and anorexia and N/V were resolved, he gained in weight, and CBC became normal, So we added  Azathioporine 100 mg/d and requested one month later visiting but he did not continue F/U unfortunately. 

Crohns disease section of Up To Date - as reference

HISTORY

�        Approximately 80 % of patients have small bowel involvement

�        As many as 10 % of patients do not have diarrhea

�        Patients can have a bowel symptoms for many years prior to diagnosis (Nonspecific digestive symptoms resembling irritable bowel syndrome)

�        Weight loss is a common complaint that is often related to decreased intake since patients with obstructing segments of bowel feel better when they do not eat.  

PHYSICAL EXAMINATION

�        Physical examination may be normal or show nonspecific signs (pallor, weight loss) or findings suggestive of Crohn's disease .

Differential Diagnosis

Lymphoma, chronic ischemia, endometriosis, and carcinoid can all give a radiologic and clinical picture easily confused with Crohn's disease of the small bowel

Radiologic Diagnosis

�        Typical radiologic features of small bowel Crohn's disease include narrowing of the lumen with nodularity and ulceration (which can also be seen with Crohn's colitis), a "string" sign when luminal narrowing becomes more advanced or with severe spasm, a cobblestone appearance, fistulae and abscess formation when present, and separation of bowel loops, a manifestation of transmural inflammation with bowel wall thickening

EndoscopicDiagnosis

�        Push enteroscopy can be used to evaluate suspected Crohn's disease of the proximal to mid-small bowel

�         Double-balloon enteroscopy represents a major advance in the direct endoscopic inspection of the small