A Case of Crohn’s Disease

Rich Rames, M3

May/June 2013

Dr. Joy Sclamberg, Dr. James Cameron, Dr. Aditi Gulabani

• CC: RLQ abdominal pain, constipation, nausea

• HPI: 24 y/o male presents to the ED with 4-6 week h/o progressive vague abd pain with 2 weeks of constipation and watery stool with regular laxative use.

• PMH: Pyloric stenosis (2-3 months old)

• PSH: Pyloroplasty

• Pertinent negatives: vomiting, dysuria, blood in stool, no recent travel, weight loss

• Pertinent positives: fever, chills, fatigue

Clinical History

2

• Focused PE:– Abd: • Horizontal scar noted over RUQ

• Soft, non-tender, not distended

• Bowel Sounds-positive

• Pain to deep palpation of RLQ

• No rebound or guarding

• Notable Labs:– C-Reactive Protein: 181.6

–WBC: 11.68

Clinical History

• Inflammatory Bowel Disease

• Bowel obstruction

• Chronic appendicitis

• Plan– UA- negative

– Abdominal X-ray (obstruction?)

– CT Pelvis/Abd with contrast (IBD, Chronic appendicitis?)

– Colonoscopy

DDx

• Bowel wall thickening

• Mesenteric inflammation (“fat stranding”)

• Lymph node size and number

• Extra-luminal collections– Fistulae, abscesses, sinuses

What are we looking for on CT?

Pelvic Region

Post-contrast Pelvic/Abdominal CT Axial

MRN: 6561716

Accession: 5273942

Diffuse Wall Thickening of Segment of Terminal Ileum

Pelvic Region

Post-contrast Pelvic/Abdominal CT Axial

MRN: 6561716

Accession: 5273942

Normal Small Bowel

Pelvic Region

Post-contrast Pelvic/Abdominal CT Axial

MRN: 6561716

Accession: 5273942

Enterocolic Fistula

Pelvic Region

Post-contrast Pelvic/Abdominal CT Axial

MRN: 6561716

Accession: 5273942

Adjacent InflammatoryFat Stranding

Abdomen-Pelvis

Post-contrast Pelvic/Abdominal CT Coronal

MRN: 6561716

Accession: 5273942

Appropriateness Criteria

11

• CT– Radiation concerns

– GI wall thickening

– Extraluminal manifestations (e.g. abscesses)

– Quick- minutes, often used in ED settings

– Contrast allows differentiation of lumen and gut wall, no fistula visualization without it

• MR– Avoids radiation risks,

allows for serial f/u

– GI wall thickening

– Slow (45 min-1 hr)images not as sharp with patient moving and normal gut peristalsis

– Difficult to pick up subtle findings

– Improving with anti-perstaltic agents and ultrafast scans

CT vs. MR Enterography- Crohn’s

CT vs. MR Enterography- Crohn’s

CT

MR- T2 Weighted

http://www.mghradrounds.org/index.php?src=gendocs&link=2009_september

MR Enterography

http://www.radiology.ucsf.edu/patient-care/sections/pediatric/advanced-techniques/imaging2

T2 Weighted, Coronal MR Abdomen

• Inflammatory Bowel Disease

• Transmural inflammation of lining of digestive tract

• Common Signs and Symptoms– Diarrhea

– Abdominal Pain and Cramping

– Blood in stool

– Ulcers

– Decreased appetite and weight loss

Crohn’s Disease

• Complications– Bowel Obstruction

– Ulcers

– Fistulas– Anal Fissure

–Malnutrition

– Colon Cancer

Crohn’s Disease

• Following CT- patient admitted

• Colonscopy– Ileocecal valve: severe ulceration, granularity and

erythema with deformation of the valve

– Single ulcer in sigmoid colon, polyp

• Discharged after with appropriate medication- repeat labs in 2 weeks

Follow Up

• learningradiology.com/notes/ginotes/crohnsdiseasepage.htm

• www.mayoclinic.com/health/crohns-disease/DS00104

• http://emedicine.medscape.com/article/367666-overview

• http://www.mghradrounds.org/index.php?src=gendocs&link=2009_september

References

• Questions?