An Unusual Case of Small Bowel Limited Crohnʼs Disease Presenting as Recurrent Intestinal Obstructions Diagnosed by Capsule Endoscopy and Double Balloon Enteroscopy

Abstract

Purpose: This case was an unusual presentation of Crohn's Disease in an elderly female with recurrent small bowel obstructions. Capsule endoscopy and double balloon enteroscopy as diagnostic tools are described and the use of TNF-alpha inhibitors in the elderly is discussed. Case Report: An 85 year old woman presented with nausea, vomiting, and weakness. She was found to have recurrent small intestinal obstructions. Contrast CT of the abdomen/pelvis showed small bowel dilatation in the proximal small bowel and a transition point without complete obstruction. Contrast passed through the transition point and segmental wall thickening was noted in the distal small bowel. EGD/colonoscopy were unrevealing. Capsule endoscopy revealed multiple concentric ulcers with narrowing of the small bowel lumen. The capsule was retained. Double balloon enteroscopy revealed the ulcers/strictures which were biopsied and the capsule was retrieved. Biopsies of the ulcers showed marked inflammatory infiltrate of the lamina propria with lymphoid aggregates, architecture distortion and reactive atypia. A diagnosis of Crohn's disease was made and the patient was started on corticosteroids and adalimumab. She responded well during the first 3 months of therapy, then relapsed, and ultimately died from complications of intestinal perforation. Discussion: The small bowel is the most commonly affected site in Crohn's disease but only 1/3 of cases involve the small bowel alone. The most common finding on capsule endoscopy is small bowel ulcers. A bimodal peak incidence is traditionally described for IBD, but recent studies have challenged this. The peak incidence is in the 20-39 year old age group. Our patient's presentation is unusual in that she is >80 years old and because her disease was isolated to the small bowel. Patients older than 40 years old that present with Crohn's disease often have similar symptoms as younger patients but the distribution of disease is more likely to be isolated to the colon and is typically non-stricturing, and non-penetrating. DMARDs have similar efficacy in older and younger patients. Steroid use has a strong influence on mortality, increasing the odds of death 2 fold. There is no evidence that the efficacy of anti-TNF-alpha agents is altered by age. There appears to be no increased risk of serious infections compared to conventional DMARD use. Given the known risks with steroids, use of anti-TNF-alpha agents seems preferable to DMARD use plus steroids. The slight increased risk of adverse events and infections appears the same in older and younger patients although some studies show an increase absolute risk of severe infection.