Asymptomatic Presentation of a 72-Year-Old Caucasian Male Diagnosed with Small Bowel Crohnʼs Disease on the Basis of a Wireless Capsule Endoscopy (WCE) Performed Because of a Positive Fecal Occult Blood (FOB) Study: 6 Year Follow-up

Abstract

Purpose: Recognize WCE as a valuable diagnostic tool in the diagnosis of a patient with asymptomatic Crohn's disease followed for 6 years. Method: WCE was the study that was consistently positive. Case Summary: Asymptomatic 72-year-old Caucasian male had an extensive work-up in 2005 because of the finding of 1 set of stools positive for FOB. Work-up was initiated with an upper GI endoscopy, colonoscopy and a CT scan of the abdomen and pelvis, all of which were negative, followed by a WCE which revealed the presence of 30 sharply defined and somewhat deep ulcers in the jejunum and ileum. Subsequent FOB studies were negative. Previously, the patient had been on large doses of NSAIDs for joint pain. However, the patient was never anemic and except for joint pain, the patient had no GI symptoms. Initially, the patient's positive FOB was thought to be secondary to the use of NSAIDs which were immediately stopped. However, over a 6 year period up to June 2011, the patient has continued to have multiple ulcers of the jejunum and ileum and has remained asymptomatic. A small bowel intubation in 2008 during a colonoscopy revealed multiple distal ileal ulcers —“focal mild acute ileitis” by biopsy. The patient was started initially on Asacol and then switched to Pentasa 500 mg 3 tabs po tid. A total of 7 WCEs were performed, which continued to show discreet ulcerations which ranged from 30-80, with 1 study performed in 2006, which revealed only 4 ulcers. The number waxed and waned despite lack of symptoms or change in clinical behavior. Most recent tests included a normal upper GI endoscopy and colonoscopy in May 2011 with intubation of the ileum, again showing active ileal ulcerations. A CT enterography showed for the first time an abnormal loop of small bowel with mural and submural thickening compatible with a small segment of inflammatory bowel disease. The most recent WCE of May 2011 revealed 68 small to moderate size ulcers scattered throughout the small bowel with a possible ileal polypoid thickening with an ulcer on its surface. The patient continues to be asymptomatic. Conclusion: A patient with small bowel Crohn's disease with multiple small bowel ulcerations can remain asymptomatic for at least 6 years as followed by WCE.